changing landscape in provider reimbursement models presentation to national association of county...
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Changing Landscape in Provider Reimbursement ModelsPresentation to National Association of County Behavioral Health and Developmental Disability DirectorsMarch 4, 2013Sandra Forquer, PhDSVP, State Government ProgramsOptum Public [email protected]
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Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Information- and technology-enabled health services
Helping to make the health care system work better for everyone.
Health care coverage and benefits
Helping people live healthier lives.
Optum Is Part of UnitedHealth Group
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“A shift toward increased collaboration
between payors and providers is driving
innovation in outcome-based payment models
and delivery system configuration.”
— Sam Ho,
Chief Medical Officer, UnitedHealth Group
Changing Landscape in Provider Reimbursement Models
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•Payment Reform Strategy
•Delivery System Strategy
Network Innovation Strategy to Increase Value
• We are developing and implementing a suite of value-based incentive programs that reward care providers for improvements in quality and efficiency
• We are supporting delivery systems as they become more integrated and accountable for cost, quality and experience outcomes
• Alignment across our Network, Product and Clinical innovations allows us to increase value for customers and consumers
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Transition of the Model
•Compensation Continuum(Level of Financial Risk)
•Small % of financial risk •Large % of financial risk
•Moderate % of financial risk
•No Accountability •Full Accountability•Moderate Accountability
•Fee-for-service
•Performance- based Contracting
•Bundled and Episodic Payments
•Shared Savings
•Shared Risk
•Capitation
•a. 100% case by case UM
•Capitation + Performance- based Contracting
In selected provider arrangements, we will be transitioning and supporting financial risk, accountability and utilization management practices.
• Basic Q and U measurements
• b. Utilization stats review supplemented by case review
• c. Data management and system
• Modifications to achieve targets
• d. Internal ownership of performance using data management
• Max quality process and outcomes driven measurements
• Passive involvement • Provider engaged • Provider active in management • Assumes accountability
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Nearly 10% of our total spending on network-based health care services across all OptumHealth Behavioral Solutions lines of business is tied to performance-based incentive contracts that reward providers for increased collaboration, outcome-based results, and improved cost-efficiencies.
Performance-Based Contracting
CA
AZ NM
MO
GA
RI
MA
FL
OHIL
WI
MN
States with formal performance-based agreements
States with performance-based agreements in process
TX
CTIA
NE
WA
KSCO
OK
KY
NY
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Performance-Based Contracting – At A Glance
Demonstrated use of Evidence-Based Practices (EBP)
• Qualifies as High-Volume provider• Participates in periodic meetings with clinical operations staff to review data• Submits claims electronically
•Sample Facility
•Participation
•Requirements
•Sample Metrics
• Facility will earn escalator based sharing of savings if performance is within targeted range• Facility will earn performance bonus for achievement of quality metrics
•Sample Performance Incentives
• Reduction in Average Length of Stay• Reduction in 30 day Readmission rate to any inpatient LOC• Improved results on ambulatory follow-up rates (7 days post inpatient discharge)
•Incentivizing provider performance leads to better outcomes for consumers
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Feet on the Street
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• UnitedHealthcare Community Plan partnered with Recovery Connection to provide behavioral health care especially designed to meet patients at the point of need: on the street
• Recovery Connection is a program designed to manage behavioral health care for the top 195 “high-utilizer” TennCare members in West Tennessee.
EXAMPLE 1: Necessity as the Mother of Innovation
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Helping Our Members Where They Live
• A Majority of members were in the defined area of Shelby county
• West region, which includes many of these members, has a high rate of homelessness
• Higher overall expenses for members in area
• Significant problem with continuity of care in area
• Service Coordinators have a minimum of Bachelors-level education
• They are trained as a community interventional specialist, in conjunction with Neumann College, through a special curriculum
• Are supervised by a licensed Behavioral Health clinician
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EXAMPLE 1: Necessity as the Mother of Innovation
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Role of Service Coordinators
Service Coordinators are responsible for providing street-based care coordination and connections to service providers and groups.•They take part in discharge planning when members discharge from Inpatient care•Help ensure members receive timely follow-up appointments with a Behavioral Health provider after Inpatient discharge•Assist members connect with Primary Care Providers to address co-morbid conditions•Connect members with family support systems to assist in community stabilization
Pay for Performance•The Recovery Connection group is paid a basic case rate, with an identified pool for meeting performance measures:
– Initial assessments for hospital admissions with 24 hours of admission– Full assessments for all members completed with 30 days of assignment– Increases in 7-day follow-up after hospitalization (FUH) appointment– Decreases in 30-day readmissions
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EXAMPLE 1: Necessity as the Mother of Innovation
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Pilot Background & Objectives
• In New Mexico, a performance-based contracting initiative aimed at improving affordability, quality outcomes and member health was launched July 2010
• Specific objectives were to increase community tenure for consumers with history of Out-Of-Home (OOH) placements within the New Mexico public sector population
Participation Requirements
Program Execution
Payments
• Demonstrated use of EBP and support models• Minimum membership levels
• Weekly rounds with OHBS• Data reviews• Timely claims submission
ProgramStructure
Measured Outcomes
Metric Target Achievement
Reduction in OOH Units 20% 55%
Readmit Rate Not to exceed baseline by more than 2%
Readmit Rate Declined
Critical Incidents Not to exceed baseline by more than 2%
Critical Incident Rate Declined
Post-Pilot Expansion
• Identified 25 high volume facilities serving both commercial and public sector members as part of a phased implementation effort
• Aligning incentives to achieve reduction in ALOS, readmissions, and improvements in HEDIS 7-day ambulatory follow up
• Provider has opportunity to earn rate escalator based on achievement levels
Pay-for-performance Contracting Improves System of Care
EXAMPLE 2: Necessity as the Mother of Innovation