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Arizona Behavioral Health Payment Reform Toolkit Project Kick-Off “Boot Camp”
DAY 1 Curriculum (February 5, 9:00am – 5:00pm) Welcome, Boot Camp Agenda and Overview
Project Goal: Develop an Arizona Behavioral Health Payment Reform Toolkit that can be used by the RBHAs and Provider Agencies to support movement toward the triple aim.
Seven Toolkit Chapters
1. RBHA and Provider Readiness Self-Assessment Tools 2. Menu of Triple Aim Transformation Strategies 3. Menu of Alternative Payment Models 4. Pay for Performance Strategies 5. Information Technology Requirements 6. Regulatory Implications 7. Implementation Strategies
Boot Camp Objectives
1. Gain a deeper understanding of the interconnectedness of the people, services, and money.
2. Connect payment reform to system transformation. 3. Learn about a recommended approach to behavioral health payment reform. 4. Begin to form opinions about how that payment reform approach will need to be
modified to fit each of the Arizona RBHAs. 5. Organize the workgroups that will be developing the toolkit. 6. Have fun!
Module 1: Transformation Strategies and Return on Investment (ROI)
Break
Module 2: A Recommend Approach to Payment Reform
Lunch (60 minutes)
Module 3: Designing an Alternative Payment Model at the Payor Level to Achieve the Triple Aim
Break
Module 4: Organizing at the Provider Level to Succeed under Alternative Payment Models
Post It Exercise
Meeting Evaluation and Adjourn
Day 2 Curriculum (February 6, 9:00am – 12:00pm)
Debrief Day 1 – Learnings and Questions
Module 5: Developing a Pay for Performance System
Break
Organizing the Workgroups and Meeting Schedule
Evaluation and Adjourn Sponsored by
Arizona Council of Human Service Providers, MCAP, Behavioral Health Coalition of Southern Arizona, Cenpatico, Community Partnership of Southern Arizona, Mercy Maricopa Integrated Care, and Northern Arizona Regional
Behavioral Health Authority
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Arizona Behavioral Health Payment Reform Toolkit
Project Kick-Off “Boot Camp”February 5-6, 2015
Dale Jarvis, CPAKaren Linkins, PhDJennifer Brya, MA, MPP
Project Goal
• We are coming together to develop an Arizona Behavioral Health Payment Reform Toolkitthat can be used by the RBHAs and Provider Agencies to support movement toward the Triple Aim.
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Seven Toolkit Chapters1. RBHA and Provider Readiness Self-
Assessment Tools2. Menu of Triple Aim Transformation
Strategies3. Menu of Alternative Payment Models4. Pay for Performance Strategies5. Information Technology Requirements6. Regulatory Implications7. Implementation Strategies
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Our vision is a web-based toolkit that contains written material we’ve created, Excel tools that RBHAs and providers can use, resource documents from other sources, web links to great stuff including you tube talks, and anything else that will be helpful.
Project Timeline
• February: Kickoff and First Workgroup Webinars
• March: Workgroup Webinars Continue
• Early April: Face to Face Design Session
• Mid April: Workgroup Webinars Continue
• Late April: Face to Face Design Session
• May-June: Finalize and Roll Out Toolkit
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Boot Camp Objectives1. Gain a deeper understanding of the interconnectedness of
the people, services, and money.2. Connect payment reform to system transformation.3. Learn about a recommended approach to behavioral
health payment reform.4. Build an outpatient behavioral health case rate system in a
small group simulation.5. Begin to form opinions about how that payment reform
approach will need to be modified to fit each of the Arizona RBHAs.
6. Organize the workgroups that will be developing the toolkit.
7. Have fun!
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Agenda – Day 1• Agenda Review and Overview • Module 1: Transformation
Strategies and Return on Investment (ROI)
• Module 2: A Recommended Approach to Successful Payment Reform
• Module 3: Designing an Alternative Payment Model at the Payor Level to Achieve the Triple Aim
• Module 4: Organizing at the Provider Level to Succeed under Alternative Payment Models
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Agenda – Day 2
• Debrief Day 1 – Learnings and Questions
• Module 5: Developing a Pay for Performance System
• Organizing the Workgroupsand Meeting Schedule
• Evaluation and Adjourn
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Why A Boot Camp: Computers, Small Groups, and a Flight Simulator
The 4 Learning
Styles
Visual(remembers names, not
faces)
Auditory
(good listener, talks out
problems)
Kinesthetic
(learn by doing, not watching or
listening)
Tactile
(takes notes, hands on activities)
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• But most important, this is not a workshop or training (where you might retain 10% of the material).
• This is the beginning of a process that requires your active involvement to ensure that the product supports your future financial viability.
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Payment Reform Flight Simulator
• The airline has two big lessons for healthcare:
– Use a preflight checklist before surgery (Atul Gawande, The Checklist Manifesto)
– Practice flying in a Flight Simulator before you try it in a real plane.
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Payment Reform Flight Simulator• Excel Workbook with 6 tabs
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After Lunch Today• Module 3: Designing an Alternative Payment
Model at the Payor Level
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Later This Afternoon• Module 4: Organizing at the Provider Level to
Succeed under Alternative Payment Models
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What’s In Your Boot Camp Packet• Agenda
• PowerPoint Slides
• Flight Simulator Printout
• Small Group Worksheets for Modules 1, 3,4,5 and Transformation Strategies List
• Workgroup Descriptions
• Meeting Schedule for Workgroups
• Link to Michael Porter Article: How Should We Pay for Health Care? http://hbs.me/1wp0pZB
• Dale Jarvis Paper: Case Rate Toolkit – Preparing for Bundled Payments, Case Rates and the Triple Aim
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Ground Rules for Successful Boot Camp Engagement
1. Speak one at a time.
2. Keep discussion moving- we want new ideas.
3. Limit multi-tasking (texting, checking email, social media); use designated break times & lunch.
4. Be brilliant – but brief.
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Module 1: Transformation Strategies and Return on Investment (ROI)
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Paul Keckley, Healthcare Thought Leader and Smart Guy
• The New Rule of Healthcare Economics:
• “Don’t expect to get paid more tomorrow for the same work you’re doing today.”
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The Problem with the Care System for People with Behavioral Health Disorders
Too Little Effective Care Too Much Sick Care
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Theory of Change/Logic Model
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1. As-Is State: Funding
and Services fragmented;
most money flows after
you get sick
3. Deployment of First
Round of High Impact
Strategies focused on
High Cost Individuals
4. Reduce Hospital,
Emergency Room,
Imaging, and Medical
Specialty Spending
5. Integrated Funding
allows a region to
Recycle Savings into
Second Wave in Triple
Aim Initiatives
2. Integrated Funding
and Commitment from
All to Support Integrated
Care to Reduce Morbidity
and Mortality
6. To-Be State: Reduced
Morbidity and Mortality,
Increased Wellness,
Better Costs
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Oregon’s Results July 2013 – June 2014
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Paying Close Attention to ROI• Change does not always equal Improvement.• Not all innovations have a Return on Investment.
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Washington State Project
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This tool will be included in the Arizona Toolkit!
Exhibit A
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Today’s Triple Aim Strategies Menu• Strategy 1: MHIP Program or Lookalike• Strategy 2: Medication Assisted Treatment in Primary Care• Strategy 3: BHC-Based Care Management Program• Strategy 4: BHC-Based Primary Care Clinic• Strategy 5: Community-Based Care Coordination Team ("Hot Spotting")• Strategy 6: Community Health Worker (CHW) Program for Adult• Strategy 7: Supportive Housing-Based Care Management• Strategy 8: Hospital/ER-Based SBIRT
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1) Organize for
Sustainability
2) Serve
High Cost
Individuals
3)Track and
Analyze Health
Cost & Utilization
4) Build the
Business
Case
Creating Your Sustainability Plan
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4-Step Sustainability Plan1. Organize for Sustainability
– Become Best Friends with the Health Plans serving your Clients
– Develop a Hot Spotting Strategy
– Develop Tracking Systems
2. Serve High Cost Individuals
– Successfully wrapping care around those with high healthcare costs
– Becoming emergency room and hospital prevention systems
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4-Step Sustainability Plan3. Track and Analyze Cost and
Utilization Data
– Triple Aim Initiative Utilization & Cost
– ER, Inpatient, Outpatient Hospital, Specialty Medical Utilization & Cost
4. Build the Business Case
– Compute the Actual and Projected Cost Savings
– Develop a Return On Investment (ROI) Analysis
– Pitch the Business Case to Payors to Fund the Program Shortfall on an Ongoing basis through the Healthcare SavingsP&L Overhead
Departments
Revenue
Expense
Excess(Deficit)
P&L Service
Departments
Revenue
Expense
Excess(Deficit)
Financial Accounting System
Service
Records
Direct Cost
Indirect Cost
Total Cost
Service
Records
Date
Provider
CPT Code
Diagnosis
Charge
Patient Accounting System
Cost
Alloca-
tion
System
Micro-Costing or RVUs
Direct Costs
to Services
Overhead
Costs to
Services
Information Reporting System
25%
25% 25%
25%
10
0 9080
7060
5040
3040
5060
70
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Expand the Program(and keep building)
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Module 1: Small Group Exercise
• Small Group Background:– You will gather at your table based
on your small group number.
– This is the group you will be working with for the next day and a half.
– Simulation Scenario: • You are a multi-disciplinary design team
within a fictional region in a fictional state named Arizona.
• Your design team is made up of MCO staff, providers, and consumers and advocates.
• You have important problems to solve.
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Module 1 Small Group Exercise• Small Group Organizing:
– Introduce yourselves– Choose a pilot (who will operate the computer for later modules)– Choose a recorder (who will take careful notes about the changes)– Choose a timekeeper (who will make sure to keep you on task)
• Small Group Exercise:– Individual Assignment: Read the list of Practices with ROI evidence and put a
checkmark next to the ones that appear to have relevance to your Region’s Target Population.
– Small Group Work Step 1: Discuss any practice you’d like to add to the list.– Small Group Work Step 2: As a group, code each practice as follows:
a) This is widely in use in the Arizona Medicaid systemb) This is somewhat used in Arizona and should be expandedc) This is not really used in Arizona and should be expandedd) None of the above
– Small Group Work Step 3: Your region is going to receive a $2 million Transformation Grant to implement two Initiatives that have a high probability of achieving the Triple Aim for Medicaid enrollees in your region with behavioral health disorders.• Identify your two priority initiatives.• Describe the sub-population that will be served by each initiative.• Write a brief description about why each will be a good investment. 29
Break Time
• Followed by Small Group Check-In.
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Module 2: A Recommend Approach to Payment Reform
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5-Step Process1. Identify your
Problem Areas and Develop Transformation Strategies
2. Determine and Size Your Funding Pools
3. Develop the Payment Models in Each Funding Pool
4. Design the Pay for Performance System
5. Develop Needed Plan and Provider Infrastructure
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1. Identify Your Problem Areas and Develop
Transformation Strategies
2. Determine and Size Your Funding Pools
3. Develop the Payment
Models in Each Funding Pool
4. Design the Pay for
Performance System
5. Develop Needed Plan and Provider Infrastructure
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Step 1: Identify your Problem
Areas and Develop
Transformation Strategies
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Step 2: Determine and Size the Funding Pools
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Health Plan Funding Pools• Budgets for each major
category of care and provider type.
• Providers in each pool hold some degree of risk based on the payment model.
• Initial pool sizes based on history with goal to right-size over a defined time period.
• A major problem with the US healthcare system: current pools are weighted toward “sick care” system.
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Where Many Systems are Headed• Reduced Inpatient Admissions, Days, and Cost per Day + Reduced
Emergency Department Visits + Reduced Diagnostic Imaging + Reduced Specialty Procedures =
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Step 3: Develop the Payment Models in Each Funding Pool
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Menu of Payment Models
1. Capacity Funded
2. Fee for Service/Per Diem
3. Stratified Case Rate/Bundled Payment
4. Global Budget
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Payment Mechanisms1. Capacity Funded: The Fire Department
model; identify the staffing requirements and buy capacity.
2. Fee for Service/Per Diem: Payment for all authorized visits or days, paid at an agreed rate. This also includes bundled per visit (FQHC and CCBHC PPS) and bundled per diem.
3. Stratified Case Rate/Bundled Payment: Payment of a flat fee per patient for a predefined episode at a specific level of care, regardless of how much time and money was spent (e.g. Hospital DRGs and Mental Health Case Rates).
4. Global Budget (Sometimes called Partial Capitation): A set monthly budget for every assigned patient for a portion of their care. The emerging model for Primary Care.
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How to Decide Which Payment Model to Use?
• The Risk Triangle tells us that there are 5 types of Financial Risk.
• The Provider Payment Model is how Risk and Flexibility is Transferred from the Payor to the Provider.
• Theoretically, you wantto use the Provider Payment Model thatmoves as muchRisk and Flexibilityto the Provider asthey can handle.
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Types of RiskIn the Risk Triangle
1. Cost: Services cost more per unit than payment rates per unit.
2. Utilization (Individual): Individuals, on average, use more units of service than estimated.
3. Utilization (Case Mix): The mix of patients is weighted toward higher severity or complexity than estimated.
4. Penetration: More individuals from the covered population use services than estimated.
5. Population: The population requiring coverage grows faster than originally estimated (Held by Purchaser).
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Let’s Try a Case Rate Scenario• The provider is being paid case rates for 80 people.
• There are two levels of care: Level 1 and Level 2.
• Individuals at both levels , on average, use more units of service than planned.
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Let’s Try a Global Budget Scenario• The provider is being paid a fixed per member per month amount
to provide outpatient mental health care to all that need it.
• We’re using the same assumptions as the Case Rate Scenario: Individuals at both levels , on average, use more units of service than planned.
• Plus, more people present for care than planned.
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Distribution of RiskAmong Providers, Plans
and Purchasers
Distribution of Risk
Fee for
Service
Stratified
Case Rate Capitation
Cost Risk provider provider provider
Individual Risk plan provider provider
Case Mix Risk plan plan provider
Penetration Risk plan plan provider
Population Risk purchaser purchaser purchaser
Types of Flexibility and RewardIn the Risk Triangle
• Fee for Service: Limited Flexibility; Reward if services cost less per unit than payment rates per unit (e.g. not much risk or reward).
• Care Rate: Not tied to counting widgets – much more flexibility to provide the right care in the right setting; Reward if individuals, on average, use less units of service than estimated.
• Global Budget: Even greater flexibility; Reward if individuals use less service, are able to help people move toward recovery, lowering case mix, or have fewer needing care because of your prevention and early intervention efforts.
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Let’s Try a 2nd Global Budget Scenario• We’re using the same basic assumptions, but with favorable
numbers that are due mainly to the provider implementing a series of triple aim strategies internally in their organization.
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Risk, Reward and Incentives
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Step 5: Develop Needed Plan and Provider Infrastructure
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Brainstorm at Your TableWhat questions do you have about:
1. Funding pools?
2. The four payment models?
3. Connecting service areas to payment models?
4. How provider risk increases as you go down the risk triangle?
5. How provider flexibility and reward increases as you go down the risk triangle?
6. Anything else from Module 2?
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1. Identify Your Problem Areas and Develop
Transformation Strategies
2. Determine and Size Your Funding Pools
3. Develop the Payment
Models in Each Funding Pool
4. Design the Pay for
Performance System
5. Develop Needed Plan and Provider Infrastructure
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Module 3: Designing an Alternative Payment Model at the Payor Level
to Achieve the Triple Aim
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Module 3 Assumptions• Each Small Group represents a RBHA Alternative
Payment Model Design Team.
• Your Job is to develop a Mental Health Outpatient Case Rate System for your Region.
• Part 1: Full Group Walkthrough of the Case Rate Development Steps.
• Part 2: Small Group Case Rate Design Project.
• Part 3: Full Group Discussion of Key Learnings.
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Why Start with Case Rates?
• Key Concept:
– If you do it “right”, each of the Big 3 Payment Models…• Fee for Service
• Case Rates
• Capitation
– Require the same “Ingredients”
1. Enrollment
2. Penetration Rate
3. Levels of Care
4. Case Mix
5. Utilization
6. Unit Cost
– Case Rates may do the best job connect the dots.
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The 10-Step Case Rate Model Design Process
Step 1: Identify Your Aims
Step 2: Define the Population
Step 3: Estimate the Penetration Rate
Step 4: Define the Categories and Levels of Care
Step 5: Estimate the Case Mix
Step 6: Estimate the Average Utilization at Each Level
Step 7: Estimate the Cost per Unit of Service
Step 8: Run Multiple Scenarios, Testing for Financial Feasibility
Step 9: Identify the Feasible Scenario that Best Matches Your Aims
Step 10: Design Your Implementation Plan
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Step 1: Identify Your Aims• Develop a payment model that:
1. Contains incentives to move toward the Triple Aim.
2. Provides greater flexibility to provide the right care, at the right time, in the right setting (contrasted with the care that will generate the most volume).
3. Aligns payment with need.
4. Ensures financial accountability (to prevent taking the money and running).
5. Supports administrative simplification (to the extent possible in an era of high levels of compliance).
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A word about encounter data
• CMS requires the submission of encounters for all treatment services provided, regardless of how the services are funded.
• This is still how we report to the federal government what services were provided for the Medicaid funds.
• MUST continue to be submitted.
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Step 2: Define the Population• Admirable Mental Health Partners serves 30,000 Medicaid enrollees
across a four-county region. • The population includes newborns through older adults who are assigned
to a number of Medicaid eligibility groups that includes Medicaid expansion, non-disabled traditional Medicaid, and disabled traditional Medicaid.
• Admirable is responsible for providing a broad set of mental health services to all Medicaid enrollees that meet medical necessity criteria.
• Admirable is beginning their payment reform effort by developing outpatient case rates individuals with a serious mental illness or serious emotional disturbance who are served by the specialty behavioral health System.
• Payment models for enrollees with mild and moderate mental health disorders, substance use disorders, and co-occurring disorders will be developed in the next phase.
• Admirable has several years of utilization data for all but the Medicaid expansion population.
• Key Variable 1:
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Step 3: Estimate the Penetration Rate• Admirable must use historical data to estimate how many of the
30,000 enrollees will experience a serious mental illness or serious emotional disturbance and need community-based specialty mental health care.
• Since one can never predict the future with great precision, it will be important to identify a range.
• This metric is called the Penetration Rate.• Key Variable 2: Penetration Rate and Cases for 30,000 Enrollees
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Step 4: Define the Categories and Levels of Care
• For Medicaid enrollees with a serious mental illness or serious emotional disturbance, Admirable has organized their benefit package into the following categories, each with a designated payment method.
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Step 4: Define the Categories and Levels of Care
• Since we are developing Case Rates for the Community-Based Services category, Admirable has drilled down into this category to develop four levels of care that will be paid different Case Rates.
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Level Community-Based Services Level Descriptions
Recovery Maintenance and Health Management
(generally crosswalks to LOCUS Level 1)
Low Intensity Community Based Services
(generally crosswalks to LOCUS Level 2)
High Intensity Community Based Services
(generally crosswalks to LOCUS Level 3)
Wraparound ACT-Level Care
(generally crosswalks to LOCUS Level 4)
Level A:
Level B:
Level C:
Level D:
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Step 5: Estimate the Case Mix• In order to create Case Rates, we need to estimate how many
people will be served at each level of care. • Fortunately, Admirable has a long history of utilizing the LOCUS
Level of Care tool for Adults and the CALOCUS for youth. • This will greatly improve the quality of the case mix estimation
process. • If no such tool had been in place, Admirable would have had to look
to other communities for case mix figures and analyze historical utilization levels within the Admirable enrollment base.
• Key Variable 3: Case Mix
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Step 6: Estimate Average Utilization at Each Level of Care
• We have created multiple levels of care in order to ensure that organizations serving more higher-need cases receive more money and organizations serving more lower-need cases receive less money.
• Just think what would happen if provider organizations received the same Case Rate regardless of the level of need. There would be a huge incentive to “cherry pick” low need cases; a term called “adverse selection”.
• We want to remove this incentive and, if anything, create a financial incentive to serve more complex cases.
• Key Variable 4: Average Hours per Level
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Level Description Minimum Maximum Average
Level A: Recovery Maintenance and Health Management 5 15 10
Level B: Low Intensity Community Based Services 10 35 20
Level C: High Intensity Community Based Services 30 80 50
Level D: Wraparound ACT-Level Care 80 140 110
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Station Break
• We’re getting close to computing the Case Rates and the Total Case Rate Budget.
– We have estimated how many people will need community based care, the distribution of cases across levels, and how much care the average person will need at each level.
• Important Note: What Case Rates are NOT
– Case Rates are NOT a fixed budget for an individual consumer.
– Case Rates are an AVERAGE payment for all of the consumers who will be served at a given level of care.
– By definition, some individuals will require MORE care at a given Case Rate Level and some will require LESS care in order to achieve the intended outcomes.
– Case Rates are meant to provide flexibility to the provider and consumer, not lock them into a rigid box.
• Questions? Comments?
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Step 7: Estimate the Cost per Unit of Service
• Generally, the overall average cost per hour will be moved forward to the next step.
• Key Variable 5: Rate per Hour:
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Step 8: Run Multiple Scenarios• The following two tables show the first scenario based on steps 1-7. • The first table shows the Case Rate figures.• The second table computes a total annual budget for Admirable’s
community-based services.
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Finishing Steps 8 and 9
Step 1: Identify Your Aims
Step 2: Define the Population
Step 3: Estimate the Penetration Rate
Step 4: Define the Categories and Levels of Care
Step 5: Estimate the Case Mix
Step 6: Estimate the Average Utilization at Each Level
Step 7: Estimate the Cost per Unit of Service
Step 8: Run Multiple Scenarios, Testing for Financial Feasibility
Step 9: Identify the Feasible Scenario that Best Matches Your Aims
Step 10: Design Your Implementation Plan
Questions about Module 3 before we shift over to Excel?
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Small Group Work
• We are going to use the Arizona Payment Reform Flight Simulator.
• Make sure your group has identified a Pilot, a Recorder and a Timekeeper.
• You will be working with Tab 1: Rates of the Flight Simulator.
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Module 3: Small Group Instructions• Small Group Exercise:
– Decide the Name of your Small Group; enter it in cell C6 of tab 1 Rates.– Walk through steps 1 – 8 of the rate setting tab, identifying any questions you have
about the scenario. If you can’t answer any of the questions within the group, grab Dale, Karen or Jennifer.
• Balancing Activity 1– Test making changes to each variable, one at a time. – Describe the change you made.– Record the new Excess (Deficit).– Undo your change.– Repeat until you’re ready to move on.
• Balancing Activity 2– Discuss the pros and cons of changing each variable and develop an approach to
balancing the budget. – Example 1: I'm just going to change the Rate because providers can live with less. – Example 2: I'm going tweak all four variable rather than make one big change.
• Balancing Activity 3– Balance the budget and enter your changes below. – Write down your justification on the Module 3 Worksheet. – Be prepared to defend your scenario.
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Break Time
• Followed by Small Group Check-In.
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Module 4: Organizing at the Provider Level to Succeed under
Alternative Payment Models
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Module 4 Assumptions• Gear Shift: Each Small Group represents the Management
Team of a Specialty Behavioral Health Provider Organization.
• You have been part of the RBHA Case Rate Design Team and have come up with a set of Case Rates.
• You have gone back to your agency, run the numbers, and realize that you don’t have enough staff to meet demand and you will lose money under the new rates.
• Part 1: Full Group Walkthrough of the Scenario.
• Part 2: Small Group Work to Balance your Budget.
• Part 3: Full Group Discussion of Key Learnings.
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Flight Simulator Overview
• The module in pictures.
Consumers
Service Mix
Units of Service
Service Staff
Productivity Hours
Available Hours
Direct Staff Costs
Other Direct
Overhead
Risk Reserve
Enrollees
Consumers
Service Units
Capitation/Case/
FFS Rates
Demand Capacity Revenue Expense
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Module 4 Overview
• Tab 2: Utilization Management Guidelines
• Tab 3: Demand/ Capacity Projections
• Tab 4: Revenue
• Tab 5: Expenses and Excess (Deficit)
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Module 4 Highlight 1
• You’ve done your homework implementing a Level of Care system and determined that you need 31.40 Clinician FTEs.
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Module 4 Highlight 2
• You’ve counted your Clinicians and you’re 2.40 FTEs short.
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Module 4 Highlight 3
• You’ve projected your revenue.
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Module 4 Highlight 4
• You’ve calculated your expenses, and you’re 4% short.
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Full Group Walkthrough in Excel
Shift over to Excel…80
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Module 4: Small Group Instructions• Balancing Activity 1
– Is there an Excess or Deficit of FTEs? If YES, your options are…• Adjust the Clinician FTEs up or down in Step 3.• Revise the Direct Service Hours per FTE per Week by Clinician up or down in Step 1 or 3.• Revise the number of Active Clients in Step 2 above.• Do a combo of the above.
– Record your changes on the worksheet.
• Balancing Activity 2– Is there an Excess or Deficit of Revenue over Expense? If YES, work on one or
more of the following variables, but keep make sure to keep Capacity and Demand in Balance.
1) Revise the Average Hours per Client per Level of Care (Tab 2 UM).2) Revise the Clinician FTEs (Tab 3 Demand).3) Revise the Direct Service Hours per FTE (Tab 3 Demand).4) Revise Salaries or Benefits (this tab).5) Revise Other Expense (this tab).
– Note: Assume for this exercise that you cannot change any of the Revenue Variables in tab 4.
– Note: Having a large Excess is normally a sign of a problem somewhere in the system.
– Record your changes on the worksheet.
• If you finish early, take a short break.81
Post-It Exercise
• What is the most important thing I’ve learned today?
• What is the most important question I have right now?
• Write each answer on a post-it and put them up on the flip charts.
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Day 1 Evaluation
1.Enlightened and Energized
2.Enlightened and Exhausted
3.In the Dark and Energized
4.In the Dark and Exhausted
Agenda – Day 2
• Debrief Day 1 – Learnings and Questions
• Module 5: Developing a Pay for Performance System
• Organizing the Workgroupsand Meeting Schedule
• Evaluation and Adjourn
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Debrief Day 1: Learnings and Questions
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• Discuss questions and comments from the Day 1 Post-It Exercise.
• Tell us about your biggest AHA moment from yesterday…
Module 5: Developing a Pay for Performance System
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Outcomes and P4P• A Behavioral Health Center of
Excellence is known for achieving results for clients.
• The organization can measure what is important to clients and achieve excellent outcomes on those measures.
• Pay for Performance is a vehicle for incentivizing and rewarding organizations that commit to this journey.
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P4P and Outcomes• Bucket 1: The work
we do makes a measurable difference in people’s lives and we can demonstrate our excellent outcomes and high success rates with data (using validated clinical instruments).
• Bucket 2: We can’t make the above statement either because we aren’t measuring well (but we believe we provide great care), or we have started tracking outcomes and we’re not as great as we thought.
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There are two categories of P4P1. P4P can be Embedded in the Payment Model.
2. A Payment Layer is added on top of the Payment Model.
89
Four Phases of “Add-On” Payments1. Pay for Participation
– “We agree to participate in developing a ‘quality contract’ that describes the P4P design and measures.”
2. Pay for Reporting– Additional payments to support the cost of moving to a P4P
including implementation and use of health information technology.
3. Pay for Performance– Pay for hitting process targets (X% of patients have had breast
cancer exams and colorectal exams).
4. Pay for Outcomes– Paying for whether the care is “working”
• Pay for X% of patients with A1c levels under 7.• Pay a share of emergency room cost reduction.
90
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The P4P Process1. Develop the Benchmark Metric for each Measure (the
goal).
2. Identify the Baseline Metrics for each Measure for each Provider (where are you now).
3. Measure Frequently.
4. You earn your Bonus if you:
– Show Improvement, or
– Hit the Benchmark (you’re already there)
• Benchmarks may change over time, but should always be based on reasonable expectations of where the system needs to go.
91
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Paying for Outcomes• Systemwide Outcomes:
– Follow-up after hospitalization.
– Reduction in inpatient admissions per 1,000.
• Individual Outcomes:
– Major experiment unfolding in the Portland Oregon area –rollout of an Outcomes-Based Care/Treat to Target Initiative.
• You Need to Have Both in Place!
93
System-Wide Outcomes CCBHC Sidebar
• On Monday February 2nd, SAMHSA released their draft Criteria for what it will take to become a Certified Community Behavioral Health Clinic.
• Comments are due February 16th.• Section 5 contains 3 pages of
draft “Quality and Other Reporting Requirements”.
• Appendix A contains 16 pages of 18 pages of potential Quality Measures, almost all of which are system-wide outcome measures.
http://www.samhsa.gov/about-us/who-we-are/laws-regulations/section-223
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Treat to Target/Outcomes-Based Care1. A multidisciplinary care team works with
an individual with behavioral health disorders to complete a multi-dimensional assessment;
2. The assessment is used to identify specific and measurable goals for the individual including at least one clinical goal and one personal goal;
3. The client and their team develop a professional care plan and self-care planthat includes setting targets related to the goals, utilizing validated tools to measure improvement;
4. The team supports client engagementthroughout the process, engaging the client in all aspects of the care planning and treatment, understanding how the client is progressing through the stages of change, and providing high-touch care management;
5. The client and team monitor progress in a persistent and individualized way to determine whether the care is working, using the clinical measurement tools to determine whether the targets are being reached;
6. There are regular case reviews with the team and with the client to determine whether the care plan is working or needs adjusting; if targets are not being met, care plans are changed;
7. Electronically shared information is available to all members of the care team, ideally through the use of a patient registry, including the care plans, medication list, and results from the outcomes tracking tools;
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What Makes a Treat to Target Tool?Portland’s Clinical Tools Menu Criteria
The following criteria are included to help ground us in both the tools and how to use them.
1. The tool must measure a clinically relevant symptom, function or behavioral domain.
2. The tool must use a scoring scale that supports the ability to do sequential measurement and has a track record for reliability and validity.
3. The tool must help the client and clinician determine whether the client is making progress.
4. The tool must be short and preferable self-reported by consumer/client when possible.
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Current List of Portland’s Tools
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w ww.T he Na t io na lC ou nc i l . o rg
What percentage of your clients meet the “quick definition” of Treat to Target?
1. Over 2/3
2. 1/3 to 2/3
3. 0% to 1/3
4. I don’t know
Paying for Outcomes Question:
Quick Definition of Treat to Target
I have at least one short-term clinical goal that’s measured on a regular basis (monthly, weekly, every visit) and my care plan and/or self-care plan is adjusted if my goal is not being met.
Measurement tools include the PHQ-9, GAD, MDQ, etc.
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Module 5: Small Group Instructions• The Task for Your Small Group:
– Develop a Behavioral Health Pay for Performance Program for your Region.
– Feel free to steal shamelessly from the Portland project.– Keep in mind the Four Phases of Add-On Payments (slide 90)
• Rules for the Exercise:– The Program has to be organized around a Treat to Target approach to
Outcomes at the Individual Client Level. – Phase 1 of the Program has to be ready to go live within 90 days.– The Program has to have at least 2 Phases.
• Questions to Answer:1. What is the Name of your P4P Program?2. What is the Aim/Goal of your P4P Program?3. Provide a brief description of your Program Design.4. How will you use Add-On Payments to support the Program in each
Phase (picking from the 4 Phases on slide 90)?5. How will you determine whether a Provider Organization has earned
their P4P Bonus in each Phase?
• If you finish early, take a short break. 101
Questions or Comments?
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Organizing the Workgroups and Meeting Schedule
103
Workgroup Overview1. What is the intended purpose and audience for the tool kit?2. What are the different groups/topics and the anticipated timeline,
format, and structure? 3. What is the type of information that will be covered in each
group/topic?4. What is the ideal composition/number of members of
workgroups?5. What are the proposed meeting dates and time commitments for
each workgroup?Organizing the Workgroups
• Sign up on big sheets on walls around the perimeter of the room. • If time, pre-convene each workgroup for a meet and greet face-to-
face.
Workgroups
1. Population, Service Areas, Payment Models
2. Pay for Performance Design
3. Information Technology Requirements
4. Regulatory Requirements or Provider Readiness (pick one)
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105
Day 2 Evaluation
1.Enlightened and Energized
2.Enlightened and Exhausted
3.In the Dark and Energized
4.In the Dark and Exhausted
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Welcome to the ...
Payment Reform Flight SimulatorWe Hope Your Stay is a Pleasant One!
Overview
This Microsoft Excel-based Toolkit contains a set of spreadsheet models to assist
your small group during the Boot Camp.
Module 3: Designing Case Rates Tab
- Case Rate Scenario Building 1. Rates
Module 4: Provider Case Rate Prep Tab
- Estimate service hours per level of care 2. UM
- Project Demand 3. Demand
- Project Capacity 3. Demand
- Balance Capacity and Demand 3. Demand
- Project Revenue 4. Revenue
- Project Expenses 5. Expense
- Balance Revenue and Expenses 5. Expense
- Estimate caseload sizes 6. Caseload
If you have any questions, please contact: Dale Jarvis at [email protected]
Case Rate Flight Simulator, January 2014, Page 1Packet Page 56
Payment Reform Flight Simulator1. Case Rate Scenario Building RBHA Excess(Deficit): -$1,059,234
Team Name: Your Team's Name Here
1. What is the Population 30,000
2. How many people will be served?
Penetration Rate 10%
Number of Clients 3,000
3. How will they distribute across Level A 20% 600
levels of care? Level B 37% 1,110
Level C 33% 990
Level D 10% 300
100% 3,000
4. How much care will the average Level A 10 Clinician Hours
person need at each level? Level B 20 Clinician Hours
Level C 50 Clinician Hours
Level D 110 Clinician Hours
5. What's the Average Cost per Hour? $158.62
Clients Hrs/Client Total Hours
6. What are the Total Costs if our Level A 600 10 6,000
Estimates are Accurate and we Level B 1,110 20 22,200
paid Fee for Service? Level C 990 50 49,500
Level D 300 110 33,000
Total Hours 110,700
Average Hourly Rate $158.62
Total Costs $17,559,234
Hrs Rate Amount
7. What are the Case Rate amounts? Level A 10 $158.62 $1,586
Level B 20 $158.62 $3,172
Level C 50 $158.62 $7,931
Level D 110 $158.62 $17,448
8. What is the total Case Rate Budget? Clients Case Rate Total $
Level A 600 $1,586 $951,720
Level B 1,110 $3,172 $3,521,364
Level C 990 $7,931 $7,851,690
Level D 300 $17,448 $5,234,460
Total $17,559,234
Available Funding $16,500,000
|---------------- OOPS --------------------> Excess (Deficit) ($1,059,234)
|---------------- OOPS --------------------> Excess (Deficit) % -6%
Case Rate Flight Simulator, January 2014, Page 2Packet Page 57
Payment Reform Flight Simulator1. Case Rate Scenario Building RBHA Excess(Deficit): -$1,059,234
Hrs Clients Average
9. What's the Blended Case Rate? Total 110,700 3,000 36.90
Rate $158.62
$5,853
10. What's the Capitation Rate? Budget $17,559,234
Covered Population 30,000
Per Member Per Year $585.31
Per Member Per Month $48.78
11. Balancing the Budget Exercise
You have 4 variables you can adjust:
A. Penetration Rate C. Hours per Case
B. Case Mix D. Cost per Hour
Balancing Activity 1
Test making changes to each variable, one at a time.
Record the change you made.
Record the new Excess (Deficit)
Balancing Activity 2
Discuss the pros and cons of changing each variable and develop an approach
to balancing the budget.
Example 1: I'm just going to change the Rate because providers can live with less.
Example 2: I'm going tweak all four variable rather than make one big change.
Balancing Activity 3
Balance the budget and enter your changes on the Module 3 Worksheet.
Write down your justification on the Module 3 Worksheet.
Be prepared to defend your scenario.
Case Rate Flight Simulator, January 2014, Page 3Packet Page 58
Payment Reform Flight Simulator2. Utilization Management Guidelines Agency Excess(Deficit): -$172,154
Team/Program/Agency Name:
This tab lists the range of hours that would generally expected to be provided at a given
level of care; and the average hours that we should shoot for with all clients on a team,
program or agency-wide, based on the Case Rates being paid by your Medicaid payor.
Hours per Client per Episode
Hours Hours Average Payment
Level Low End High End Hours Hours
Level A: 5 15 8.0 8.0
Level B: 10 35 18.0 18.0
Level C: 30 80 48.0 48.0
Level D: 80 140 96.0 96.0
Client Average Length of Stay
What is the average length of stay for cases at each level (in months)?
Level A: 4 months
Level B: 6 months
Level C: 9 months
Level D: 12 months
Client Demand
What are the average hours per client per week provided by you?
How many clients could one FTE see if they were only seeing clients at one level of care?
Hours per Week: 24 Direct Service Time per FTE per Week
Client Client
Hours/Wk per FTE
Level A: 0.47 52 Note that the client hours per week
Level B: 0.70 34 calculation is based on Payment Hours
Level C: 1.24 19 divided by the average number of weeks
Level D: 1.86 13 at each level.
Your Team's Name Here
Case Rate Flight Simulator, January 2014, Page 4Packet Page 59
Payment Reform Flight Simulator3. Demand/Capacity Projection Tool Agency Excess(Deficit): -$172,154
Team/Program/Agency Name:
Step 1: Hours per Clinical FTE per Year
How many service hours per year and per week should 1.0 FTE clinician be available
to provide direct client service?
Weeks per year 52
Vacation, Sick, Holiday, Training Weeks 6
Work Weeks 46
Hours per week 40
Hours per year 1,840
Direct
Client Time
Paperwork
& Travel
Mtgs, No
Shows, etc.
Misc.,
Other
Unproductive
Time Total Time
Percentage 60% 10% 15% 8% 7% 100%
Hours/Year 1,104.0 184.0 276.0 147.2 128.8 1,840.0
Hours/Work Week 24.00 30.67 46.00 24.53 21.47 146.67
Step 2: Active Clients and FTE Demand
Total Direct Svc Clinician
Active Avg Hrs Direct Svc Client Hrs Hours/FTE FTE
Clients per Week Hrs/Week per Year per Year Demand
Level A 100 0.47 46.5 2,419
Level B 200 0.70 139.5 7,256
Level C 275 1.24 341.1 17,736
Level D 75 1.86 139.5 7,256
Total 650 666.7 34,667 1,104 31.40
Step 3: Clinician Capacity
Direct Svc Clinician
Hours/FTE Annual
FTEs per Week Capacity
12.00 24.00 13,248
10.00 24.00 11,040
4.00 24.00 4,416
2.00 24.00 2,208
1.00 24.00 1,104
24.00 -
24.00 -
Total Capacity 29.00 1,104 32,016
Client Demand 34,667
Excess (Deficit) (2,651)
FTE Excess (Deficit) (2.40)
Balancing Activity 1
Is there an Excess or Deficit of FTEs? If YES, your options are…
- Adjust the Clinician FTEs up or down in Step 3.
- Revise the Direct Service Hours per FTE per Week by Clinician up or down in Step 1 or 3.
- Revise the number of Active Clients in Step 2 above.
- Do a combo of the above.
Peer/Paraprofessional
Psychiatrist
Nurse Practitioner
Your Team's Name Here
Clinician
Type
Master's Level
BA Case Manager
Case Rate Flight Simulator, January 2014, Page 5Packet Page 60
Payment Reform Flight Simulator4. Revenue Tool Agency Excess(Deficit): -$172,154
Team/Program/Agency Name:
Step 1: Gross Charges
Service Average Gross Direct Overhead Total
Hours Charge/Hour Charges Cost/Hr Cost/Hr Cost/Hr
Master's Level 13,248 $120.00 $1,589,760 $55.34 $64.33 $119.68
BA Case Manager 11,040 $90.00 $993,600 $41.21 $47.91 $89.12
Peer/Paraprofessional 4,416 $80.00 $353,280 $37.68 $43.80 $81.48
Psychiatrist 2,208 $500.00 $1,104,000 $235.51 $273.75 $509.26
Nurse Practitioner 1,104 $225.00 $248,400 $105.98 $123.19 $229.17
- - $0 $0.00 $0.00 $0.00
- - $0 $0.00 $0.00 $0.00
Total 32,016 $133.97 $4,289,040 $62.21 $72.31 $134.51
Step 2: Payor Mix, FFS Revenue and Contractual Allowances & Write-Offs
Service Gross Case Rate Allowance/ Net
Payor Mix Hours Charges Payor? Write-Off % Fees
Medicaid FFS 5% 1,601 $214,452 No 60% $85,781
Medicaid Case Rate 70% 22,411 $3,002,328 Yes 100% $0
Medicare 10% 3,202 $428,904 No 40% $257,342
Private Insurance 10% 3,202 $428,904 No 25% $321,678
Self Pay 5% 1,601 $214,452 No 90% $21,445
- $0 $0
- $0 $0
Total 100% 32,016 $4,289,040 $686,246
Source: (input) (calc) (calc) (input) (calc)
Note: Case Rates always have 100% Contractual Allowance; Case Rate Revenue is computed in Step 3.
Step 3: Annual Cases
Average % of Cases Case Rate
Level Active Length of "Turns" Cases Paid via Cases
of Care Cases Stay (Mos) per Year per Year Case Rate per Year
Level A 100 4 3.0 300 70% 210
Level B 200 6 2.0 400 70% 280
Level C 275 9 1.3 367 70% 257
Level D 75 12 1.0 75 70% 53
Total 650 1,142 799
Your Team's Name Here
Clinician Type
Payor
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Payment Reform Flight Simulator4. Revenue Tool Agency Excess(Deficit): -$172,154
Team/Program/Agency Name: Your Team's Name Here
Step 4: Case Rate Revenue
Level Case Rate Case Rate Case Rate
of Care Cases Payment Revenue
Level A 210 $1,120 $235,200
Level B 280 $2,520 $705,600
Level C 257 $6,720 $1,724,800
Level D 53 $13,440 $705,600
Total 799 $3,371,200
Step 5: Other Revenue and Total Revenue
$20,000
$20,000
$20,000
$60,000
$15,000
$2,000
$17,000
$686,246 (Step 2)
$3,371,200 (Step 4)
Total Revenue $4,134,446
Other Revenue
Subtotal
Fee for Service
Case Rate Revenue
Grant Revenue
XYZ Foundation
Federal Block Grant
Fundraising
Interest
Subtotal
State Grant
Case Rate Flight Simulator, January 2014, Page 7Packet Page 62
Payment Reform Flight Simulator5. Expenses and Excess (Deficit) Agency Excess(Deficit): -$172,154
Team/Program/Agency Name:
Step 1: Clinical Staffing Expense
Average Total Average Total Total
FTEs Salary/FTE Salaries Benefits % Benefits Compensation
Treatment Staff
Master's Level 12.00 $47,000 $564,000 30% $169,200 $733,200
BA Case Manager 10.00 $35,000 $350,000 30% $105,000 $455,000
Peer/Paraprofessional 4.00 $32,000 $128,000 30% $38,400 $166,400
Psychiatrist 2.00 $200,000 $400,000 30% $120,000 $520,000
Nurse Practitioner 1.00 $90,000 $90,000 30% $27,000 $117,000
- - $0 $0 $0
- - $0 $0 $0
Total Clinical Staff 29.00 $1,532,000 $459,600 $1,991,600
Step 2: Other Staff Expense
Average Total Average Total Total
FTEs Salary/FTE Salaries Benefits % Benefits Compensation
4.00 $75,000 $300,000 25% $75,000 $375,000
6.00 $32,000 $192,000 25% $48,000 $240,000
$0 $0 $0
$0 $0 $0
Total 10.00 $492,000 $123,000 $615,000
% of Clinical Compensation 31%
Step 3: Other Expense
Amount
$150,000
$500,000
$250,000
$150,000
$650,000
Total $1,700,000
% of Clinical Compensation 85%
Total Expenses $4,306,600
Total Revenue $4,134,446 (from Tab 4)
Excess (Deficit) -$172,154
Excess (Deficit) % -4%
Balancing Activity 2
Is there an Excess or Deficit of Revenue over Expense? If YES, work on one or more of the the following
variables, but keep make sure to keep Capacity and Demand in Balance.
1) Revise the Average Hours per Client per Level of Care (Tab 2 UM).
2) Revise the Clinician FTEs (Tab 3 Demand).
3) Revise the Direct Service Hours per FTE (Tab 3 Demand).
4) Revise Salaries or Benefits (this tab).
5) Revise Other Expense (this tab).
Note: Assume for this exercise that you cannot change any of the Revenue Variables in tab 4.
Note: Having a large Excess is normally a sign of a problem somewhere in the system.
Other Overhead
Category
Supplies
Rent
Travel
Professional Fees
Admin Staff
Clinician Type
Support Staff
Your Team's Name Here
Clinician Type
Case Rate Flight Simulator, January 2014, Page 8Packet Page 63
Payment Reform Flight Simulator6. Caseload Analysis Tool (Bonus Section)
Team/Program/Agency Name:
Step 1: Service Hours per Clinician FTE
How many service hours per year and per week should 1.0 FTE clinician be available
to provide direct client service?
Weeks per year 52
Vacation, Sick, Holiday, Training Weeks 6
Work Weeks 46
Hours per week 40
Hours per year 1,840
Direct Client
Time
Paperwrk &
Travel
Mtgs, No
Shows, etc. Misc., Other
Unproductive
Time Total Time
Percentage 60% 10% 15% 8% 7% 100%
Hours/Year 1,104.00 184.00 276.00 147.20 128.80 1,840.00
Hours/Work Week 24.00 4.00 6.00 3.20 2.80 40.00
Step 2: Levels of Care
How many levels do you have?
Level A
Level B
Level C
Level D
Step 3: Clinician Hours per Client per Level of Care
What are the average number of Clinician Direct Service Hours that will be provided
at each level of care?
(Note: Hours are Clinician Hours, not Client Hours)
Average
Hours
Level A 8.0
Level B 18.0
Level C 48.0
Level D 96.0
Source (UM Tab,
can be
overridden)
Step 4: Client Average Length of Stay
What is the average length of stay for cases at each level (in months)?
Level A 4 months
Level B 6 months
Level C 9 months
Level D 12 months
Your Team's Name Here
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Payment Reform Flight Simulator6. Caseload Analysis Tool (Bonus Section)
Team/Program/Agency Name: Your Team's Name Here
Step 5: Client Demand
What are the average hours per client per week provided by you?
How many clients could one FTE see if they were only seeing clients at one level of care?
Hours/Wk Clients/FTE
Level A 0.46 52 (based on available Direct Service Hours in Step 1)
Level B 0.69 35 "
Level C 1.23 19 "
Level D 1.85 13 "
Step 6: Clinician Client Mix Scenarios
What are typical clinican case mix scenarios of the ratio of clients at each level?
Clinician 1 Clinician 2 Clinician 3 Clinician 4 Clinician 5 Clinician 6
Level A 75% 40% 25% 0% 0% 0%
Level B 25% 50% 25% 25% 0% 0%
Level C 0% 10% 25% 25% 50% 25%
Level D 0% 0% 25% 50% 50% 75%
Total 100% 100% 100% 100% 100% 100%
Step 7: Client Hours Distribution
How many hours would you spend each week serving cases at each level?
Clinician 1 Clinician 2 Clinician 3 Clinician 4 Clinician 5 Clinician 6
Level A 18.00 9.60 6.00 - - -
Level B 6.00 12.00 6.00 6.00 - -
Level C - 2.40 6.00 6.00 12.00 6.00
Level D - - 6.00 12.00 12.00 18.00
Total 24.00 24.00 24.00 24.00 24.00 24.00
Step 8: Caseload Size Scenarios
Based on this analysis, how many active cases would be needed to create a full caseload?
Clinician 1 Clinician 2 Clinician 3 Clinician 4 Clinician 5 Clinician 6
Level A 39 21 13 - - -
Level B 9 17 9 9 - -
Level C - 2 5 5 10 5
Level D - - 3 6 6 10
Total 48 40 30 20 16 15
Case Rate Flight Simulator, January 2014, Page 10Packet Page 65
Page 1
Arizona Behavioral Health Payment Reform Toolkit Module 1: Transformation Strategies and Return on Investment (ROI) Small Group Exercise Worksheet
Instructions
Small Group Background:
• You will gather at your table based on your small group number.
• This is the group you will be working with for the next day and a half.
• Simulation Scenario:
– You are a multi-disciplinary design team within a fictional region in a fictional state named Arizona.
– Your design team is made up of MCO staff, providers, and consumers and advocates.
– You have important problems to solve.
Small Group Organizing:
• Introduce yourselves
• Choose a pilot (who will operate the computer for later modules)
• Choose a recorder (who will take careful notes about the changes)
• Choose a timekeeper (who will make sure to keep you on task)
Small Group Exercise:
• Individual Assignment: Read the list of Practices with ROI evidence and put a checkmark next to the ones that appear to have relevance to your Region’s Target Population.
• Small Group Work Step 1: Discuss any practice you’d like to add to the list.
• Small Group Work Step 2: As a group, code each practice as follows:
– This is widely in use in the Arizona Medicaid system
– This is somewhat used in Arizona and should be expanded
– This is not really used in Arizona and should be expanded
– None of the above
• Small Group Work Step 3: Your region is going to receive a $2 million Transformation Grant to implement two Initiatives that have a high probability of achieving the Triple Aim for Medicaid enrollees in your region with behavioral health disorders.
– Identify your two priority initiatives.
– Describe the sub-population that will be served by each initiative.
– Write a brief description about why each initiative will be a good investment.
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Page 2
Module 1 Small Group Worksheet
Strategy 1 Name:
Subpopulation to Serve:
Why is this a good investment?
Other Comments:
Strategy 2 Name:
Subpopulation to Serve:
Why is this a good investment?
Other Comments:
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Page 3
Triple Aim Strategy Candidates for Your Region’s Medicaid Enrollees with Behavioral Health Disorders
Menu of Strategies Strategy 1: MHIP Program or Lookalike Strategy 2: Medication Assisted Treatment in Primary Care Strategy 3: BHC-Based Care Management Program Strategy 4: BHC-Based Primary Care Clinic Strategy 5: Community-Based Care Coordination Team ("Hot Spotting") Strategy 6: Community Health Worker (CHW) Program for Adult Strategy 7: Supportive Housing-Based Care Management Strategy 8: Hospital/ER-Based SBIRT
Strategy 1: MHIP Program or Lookalike
Category: Behavioral Health in Primary Care
The Mental Health Integration Program (MHIP) has been developed by the University of Washington AIMS Centers. It is a best practice program that integrates behavioral health into primary care with linkages to specialty behavioral health. The program uses a well-defined set of clinical workflows supported by a care team that includes the primary care provider, a behavioral health care manager, a consulting psychiatrist, and other team members who screen, engage, treat and help patients manage their behavioral health conditions in primary care. If a patient's condition is too complex, a stepped care model is used to engage the patient in specialty care for a time limited period.
Financial and Utilization Results: Program Savings are estimated at $5,200 over four years; $1,300 per year average. This is approximately a 4:1 return on investment. A significant portion of this savings comes from reductions in inpatient admissions.
Strategy 2: Medication Assisted Treatment in Primary Care
Category: Behavioral Health in Primary Care
Buprenorhpine/Buprenorphine-Naloxone is an opiate substitution treatment used to treat opioid dependence. It is generally provided in addition to counseling therapies. Buprenorhpine/Buprenorphine-Naloxone is a partial agonist that suppresses withdrawal symptoms and blocks the effects of opioids. Two versions of buprenorphine are used in the treatment of opioid dependence. Subutex consists of buprenorphine only while Suboxone is version of buprenorphine that combines buprenorphine and naloxone. The addition of naloxone reduces the probability of overdose and reduces misuse by producing severe withdrawal effects if taken any way except sublingually. Suboxone is generally given during the maintenance phase and many clinics will only provide take-home doses of Suboxone. Buprenorphine and Buprenorphine/Naloxone are alternatives to methadone treatments and, unlike methadone, can be prescribed in office-based settings by physicians that have completed a special training.
Financial and Utilization Results: Program Savings are estimated at just under $10,000 and program costs are $4,500. This is approximately a 2.2 to 1.0 return on investment.
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Page 4
Strategy 3: BHC-Based Care Management Program
Category: Medical Care Management in Behavioral Health
Missouri's system of Community Mental Health Centers began the first statewide program of behavioral health clinic-based whole health care management based on a well-defined clinical and staffing model. The program uses a team led be a nurse care manager and staffed with case managers who have been trained to provide medical care management, supervised by a medical doctor.
Financial and Utilization Results: The initial group of highest needs clients had a net savings (after program expenses) of $500 per user per month. After significant expansion of the program the net cost savings are averaging $300 per user per month. There is no net additional cost for the first two years, i.e., investments in integrated behavioral health were offset by reductions in medical costs. For subsequent years, medical cost offsets exceed investments.
Strategy 4: BHC-Based Primary Care Clinic
Category: Primary Care in Behavioral Health
Cherokee Health Systems is one of the first FQHC systems in the country to do a large scale implementation of integrated care based on a community mental health center system being merged with a primary care clinic system. The Washtenaw Health Initiative is a second model, following a related design. Since then, the federal government has developed a grant program to fund over 100 clinics to advance the concept of a primary care clinic in a behavioral health setting.
Financial and Utilization Results: Cherokee has demonstrated 28% reduction in medical utilization for Medicaid patients and 20% decrease in utilization for patients with private insurance. A slight increase in primary care visits were offset by larger reductions in ER use, specialty care and hospitalizations.
Strategy 5: Community-Based Care Coordination Team ("Hot Spotting")
Category: Community-Based Care
In 2007, the Camden Coalition of Healthcare Providers began implementation of a citywide care management program to intervene and direct appropriate outreach to the most frequent utilizers of the emergency rooms and hospitals. The outreach teams consist of a social worker, health outreach worker/medical assistant, and a nurse practitioner. They assist with coordinating primary and specialty care, applying for benefits, securing temporary shelter, etc.
Financial and Utilization Results: The Camden effort made extraordinary progress with a seriously ill, yet engaged population. There was reduction of ER and hospital visits by 40% - 50%, with overall cost reductions of 25% - 50%. Preliminary studies had revealed that one percent of the city's population from a narrow geographic area accounted for a third of its medical costs.
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Strategy 6: Community Health Worker (CHW) Program for Adults
Category: Community-Based Care
There are an increasing number of community health worker programs that are demonstrating improved health outcomes and cost savings for a wide range of populations. This initiative draws on the Denver Health program that used CHWs to provide community outreach to adults as a means of increasing access and continuity to health care services.
Financial and Utilization Results: Average savings per month were $22,943 (5%) for 590 patients; patients received more primary care & BH services and fewer inpatient and urgent care costs. Pre-study PMPM costs were $787. ROI: 2.28 to 1.00.
Strategy 7: Supportive Housing-Based Care Management
Category: Community-Based Care
Several studies of supportive housing programs have shown demonstrated cost savings: A 67% decrease in Medicaid costs pre- and one-year post housing in Massachusetts; a 41% reduction in Medicaid costs after one year for the 1811 Eastlake Project in Seattle; 24% reduction in emergency room and 29% reduction in hospital admissions from Chicago; a 27% reduction in hospital admissions and inpatient days from the California Frequent User Initiative. All programs have care management services that focus on the whole health needs of the residents. These programs have a very successful enrollment rate; that is, with effective outreach to the most severe cases, there is little to no rejection of enrollment by the contacted individuals.
Financial and Utilization Results: Reduced Medicaid costs per above. For this initiative, we have estimated a 30% reduction in high cost services for Disabled Adults, which is consistent with the Center for Health Care Strategies 2012 Policy Brief.
Strategy 8: Hospital/ER-Based SBIRT
Category: Hospital-Based BH EBP
Patients in medical hospitals and emergency rooms are screened for "hazardous" alcohol use. Those screening positive receive a brief intervention, delivered by health care staff or other professional. The intervention includes feedback on the patients’ consumption compared to their peers and motivational interview to encourage reduction in consumption. Patients typically receive a single intervention lasting 15 minutes to one hour. Patients meeting diagnostic criteria would be referred to chemical dependency treatment.
Financial and Utilization Results: Gross savings per person range from $4,500 (hospital) to $6,000 (ER). Costs ranged from $156 (hospital) to $420 (ER). The return on investment ranged from 14 to 1 (ER) to 28 to 1 (hospital).
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Arizona Behavioral Health Payment Reform Toolkit Module 3: Designing an Alternative Payment Model at the Payor Level to Achieve the Triple Aim Small Group Exercise Worksheet
Instructions
Small Group Exercise:
• Decide the Name of your Small Group; enter it in cell C6 of tab 1 Rates.
• Walk through steps 1 – 8 of the rate setting tab, identifying any questions you have about the scenario. If you can’t answer any of the questions within the group, grab Dale, Karen or Jennifer.
• Balancing Activity 1
– Test making changes to each variable, one at a time.
– Describe the change you made.
– Record the new Excess (Deficit).
– Undo your change.
– Repeat until you’re ready to move on.
Change Description Excess (Deficit)
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• Balancing Activity 2
– Discuss the pros and cons of changing each variable and develop an approach to balancing the budget.
– Example 1: I'm just going to change the Rate because providers can live with less.
– Example 2: I'm going tweak all four variable rather than make one big change.
• Balancing Activity 3
– Balance the budget and enter your changes below.
– Write down your justification on the Module 3 Worksheet.
– Be prepared to defend your scenario.
Change Description Excess (Deficit)
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Arizona Behavioral Health Payment Reform Toolkit Module 4: Organizing at the Provider Level to Succeed under Alternative Payment Models Small Group Exercise Worksheet
Instructions
Small Group Exercise:
Balancing Activity 1: Balance Demand and Capacity in Tab 3 Demand
• Is there an Excess or Deficit of FTEs? If YES, your options are…
– Adjust the Clinician FTEs up or down in Step 3.
– Revise the Direct Service Hours per FTE per Week by Clinician up or down in Step 1 or 3.
– Revise the number of Active Clients in Step 2 above.
– Do a combo of the above.
• Record your changes below.
Change Description FTE Excess (Deficit)
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Balancing Activity 2: Balance Revenue and Expense in Tab 5 Expense
Is there an Excess or Deficit of Revenue over Expense? If YES, work on one or more of the following variables, but keep make sure to keep Capacity and Demand in Balance.
1) Revise the Average Hours per Client per Level of Care (Tab 2 UM).
2) Revise the Clinician FTEs (Tab 3 Demand).
3) Revise the Direct Service Hours per FTE (Tab 3 Demand).
4) Revise Salaries or Benefits (this tab).
5) Revise Other Expense (this tab).
Note: Assume for this exercise that you cannot change any of the Revenue Variables in tab 4.
Note: Having a large Excess is normally a sign of a problem somewhere in the system.
Record your changes below.
Change Description FTE Excess (Deficit)
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Arizona Behavioral Health Payment Reform Toolkit Module 5: Small Group Exercise Worksheet
Instructions
• The Task for Your Small Group:
– Develop a Behavioral Health Pay for Performance Program for your Region.
– Feel free to steal shamelessly from the Portland project.
– Keep in mind the Four Phases of Add-On Payments (slide 90)
• Rules for the Exercise:
– The Program has to be organized around a Treat to Target approach to Outcomes at the Individual Client Level.
– Phase 1 of the Program has to be ready to go live within 90 days.
– You must design the first 2 Phases of the Program.
Worksheet
P4P Program Name:
P4P Program Aim/Goal
Phase 1 Phase 2
Phase 1 Description:
Phase 2 Description:
Payment Type (from slide 90)
Payment Type (from slide 90)
What it takes to Earn the Bonus:
What it takes to Earn the Bonus:
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