vbp training for tier 1 cbos, primary care providers, and ...€¦ · level 0vbp* level 1vbp level...
TRANSCRIPT
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VBP Training for Tier 1 CBOs,
Primary Care Providers, and
Mental Health/Substance Use
Providers
Nassau Queens Performing
Provider System (NQP PPS)
Presented by McSilver Institute
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Agenda
• VBP Overview/Reminders
• Provider performance requirements under
VBP levels 2 & 3
• Infrastructure needs to be effective in a
VBP environment
• Role of Tier 1 CBOs in Future VBP
Arrangements - Role of Social
Determinants of Health in VBP
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Reminder: What Is Value Based
Payment (VBP)?According to CMS,
Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support our three-part aim:
• Better care for individuals
• Better health for populations
• Lower cost
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Provider Performance
Requirements under VBP
Levels 2 & 3
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Financial Payment Models
Fee For Service
Managed Care
Incentive/Pay For
Performance (P4)
Upside Risk Only
Shared Savings
Upside and Downside
Risk
Capitation/
Per Member Per Month
(PMPM)
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Level 0 VBP* Level 1 VBP Level 2 VBP Level 3 VBP
(feasible after experiencewith
Level 2; requires mature
contractors)
FFS with bonus
and/or withhold
based on quality
scores
FFS with upside-only shared
savings available when
outcome scores are sufficient
(For PCMH/IPC, FFS may be
complemented with PMPM
subsidy)
FFS with risk sharing
(upside available when
outcome scores are
sufficient)
Prospective capitation PMPM
or Bundle (with outcome-
based component)
FFS Payments FFS Payments FFS Payments Prospective total budget
payments
No Risk Sharing Upside Risk Only Upside & Downside Risk Upside & Downside Risk
*Level 0 is not considered to be a sufficient move away from traditional fee-for-service incentives to be counted
as value based payment in the terms of the NYS VBPRoadmap.Source: VBP Bootcamp #1
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Fundamentals of Partial and Full Risk
Arrangements
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Orientation to Common Risk Sharing
and Gain Sharing Arrangements
Source: VBP Bootcamp #2
• Joint
Replacemen
t
• I/DD
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Managed Care Through Shared
Risk
• Payment continues to be FFS
• Shared savings potential
– If savings and quality is achieved
• Upside and downside risk
• Lower shared savings in upside risk when
compared to upside and downside risk
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Capitation/PMPM
• Providers take responsibility for a designated population
• Providers paid monthly even if services are provided or not
• Medical loss ratio (MLR) rules usually apply
• This model is used primarily by Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs)
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Performance Standards
Standards Will Vary
Based On Payer Needs
Change Overtime
Based On Government
Measures
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Achieving Savings thru Metrics
• To achieve savings, agreed upon metrics
must be met
• Providers would need to meet all metrics
to share in savings
• For example, if provider needs to meet 5
out of 8 agreed upon measures and only
achieves 4, provider would not be eligible
to share in savings.
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Intro to Stop Loss Insurance and
Transition Considerations Moving from
Level 1 to Levels 2 & 3 Contracts
• Stop Loss Insurance – Insurance purchased to help
manage your risk; covers losses passed a certain
amount. Different levels of stop loss insurance available,
can cover:
– An individual issue (i.e. inpatient admission)
– Aggregate (total cost incurred for a patient/member)
• Transition considerations moving from level 1 to level 2 &
3
– Potential to lose money, must have the funds to cover
that
– Substantial actuarial work as part of level 2 & 312
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Infrastructure Needs in
Order to be Effective in a
VBP Environment
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Infrastructure Needs
• Flexible/Adaptable
• Responsive to agency needs
• Ability to connect finance and clinical data
• Beyond connection, multidimensional: able to
accommodate the nuances of how finance
and clinical data influence each other
• Ability to handle data from multiple platforms
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Discussion
• What are ways that your organization has
increased or could increase the flexibility
and interconnectedness of your
infrastructure?
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Infrastructure Areas• Ongoing IT support and development:
– Hardware
– Software
– Staffing
• Finance– New financial structure/reporting
– Budgeting/projections
– Staffing
• Human Resources:– Hiring and Promotion Practices
– Training and Development of Performance Driven Culture
– Job description/skills
• Ongoing quality improvement support and development:– Tool development
– Staffing
• Data and Analytics– Technology
– Staffing
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Data
• Common data set
• Standard data format
• Actionable
• Data dictionary
• Interoperability
• Comprehensive
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Data Considerations and Barriers
• Tangible Improvements
• Real time vs. Batch
• Visualization vs. Reports
• Data collection
– Direct staff
– Data entry
• Client identification across systems
• HIPPA/42 CFR protected information and consent
• Interoperability standards
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Discussion
• What types of data are you already
collecting?
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Data Sets
• Government/Grantor
– Demographics
– Reports
– Payment data
• Payer
– Demographics
– Medicaid
– Medicare
– Private/Commercial Insurance
– Utilization Management
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Data Sets Continues
• Regional Health Information Organizations (RHIO)
– Demographics
– Clinical
– Payer
• Provider
– Demographics
– Clinical
– Service/Billing
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Role of Tier 1 CBOs in Future VBP
Arrangements - Role of Social
Determinants of Health in VBP
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Social Determinants of Health
Those factors that impact upon health and well-
being: the circumstances into which we are born,
grow up, live, work, and age, including the health
system. World Health Organization: 2008.
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20January 2018
The 5 Domains of Social Determinants
of Health (SDH)
Education
Social and Community
Health and Health Care
Neighborhood and
Environment
Economic Stability
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Your ZIP code may be more
important to your overall health
than your genetic code
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Discrimination Persists
‣ Pairs of young, well-groomed, well-spoken college men
with identical resumes applied for 350 advertised entry-
level jobs in Milwaukee, Wisconsin.
‣ Two teams were black and two were white. In each team,
one said that he had served an 18-month prison sentence
for cocaine possession.
‣ The study found that it was easier for a white male with a
felony conviction to get a job than a black male with no
criminal record.
Source: Devan Pager; NYT March 20, 2004
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Behavioral Health Related Outcomes Associated with Poverty and Income
Inequality
‣Depressive disorders
‣Poor self-reported mental health
‣Drug overdose deaths
‣Juvenile homicides
‣Those involved or previously
Involved with the justice system
‣Anxiety disorders
‣PTSD
‣Increased arrests
‣Cognitive, behavioral,
and attention-related
problems in children
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Health Impact of Substandard Housing Conditions
‣Increased asthma
‣Increased lead poisoning
‣Injuries
•Radiator burns
•Window falls
•Fires from improper wiring, lack of smoke detectors, use
of space heaters
‣Increased infectious diseases
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Impact of Insufficient Access to
Food/Nutrition• Unhealthy diet due to lack of access to fresh fruits,
vegetables and other healthy food options
– Increases obesity, high blood pressure, heart disease and stroke, diabetes, and some cancers
– Increases stress, depression, and other mental illnesses
• Not having enough food to feed yourself and your family
– Children: negatively impacts their ability to learn and develop/grow properly which increases chronic illnesses (i.e. asthma) and behavioral problems and can have lifelong effects
• Education is another social determinant of health
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Discussion
• Have you witnessed the effects of Social
Determinants of Health in your work? In
what ways?
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Ineffective Practices
Despite the high rates of mental health problems manifested by
the underprivileged in the United States, people living in poverty
routinely underutilize counseling services and often prematurely
terminate counseling when they do access such services (Coiro,
2001; Gonzalez, 2005).
Not understanding client’s circumstances can lead to treatment
that is not relevant and/or meaningful to clients.
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Examine agency policies to
determine if they may be
inadvertently limiting access to
the disenfranchised
Policies
Do you recruit, retain, and promote a diverse group of
staff with knowledge, skills, and experience in
serving diverse populations?
Staffing
Has your agency identified and
articulated engagement
practices/standards for staff to utilize
when serving hard to reach populations?
Delivery
Awareness of SDH is Crucial to
Changing Health Outcomes
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Tier 1 CBOs in future VBP arrangements -
Role of social determinants of health in
VBP • Addressing social determinants of health can
improve outcomes– Many performance measures are impacted with
Social Determinants of Health
• Benefits of Tier 1 CBOs– Enmeshed in the community
• have built trust
• culturally competent
– Already involved in work to address social determinants of health (improve housing conditions, increase access to healthy food, increased access to resources)
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Resources
• New York State DOH
https://www.health.ny.gov/health_care/me
dicaid/redesign/dsrip
• VBP Arrangement Fact Sheet
https://www.health.ny.gov/health_care/medicaid/
redesign/dsrip/vbp_library/index.htm
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Questions?
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