The move to value-based reimbursement (VBR) across the health and human services industry has become a driving force across both public and private sector organizations, not only forcing new operating models and systems, but pushing providers to develop new partnerships with payers and to prepare for population health management. For executives and leadership of provider organizations, the transition to VBR presents organizational, technical, and cultural challenges that will impact many areas of the business model. As leaders develop strategy, it is important to incorporate tactics to transition their organizations from success in the current hybrid FFS/VBR market—to success in a mature VBR market.
To help provider organizations navigate the management challenges of this transition, OPEN MINDS has developed a web-based readiness self-assessment for value-based reimbursement readiness, focused on scoring organizational and technical competencies needed to make the transition successful. This tool was designed to evaluate and identify improvements in the following domains:
- Care Coordination & Care Management—Sharing data along the way
- Clinical Management & Clinical Performance Optimization—Data analyzed to drive clinical decision-making
- Consumer Access, Service Engagement—Processes to empower consumers and create engagement
- Financial Management—Revenue cycle management and accounting procedures to support contracts
- Provider Network Management—Strategies to enhance provider networks
- Technology & Reporting Infrastructure—Data leveraged to gain insight
- Leadership & Governance—Alignment of strategy with infrastructure and resources
All health care organizations should be planning for VBR and other alternative payment models. Conducting a gap analysis is a first step to planning this paradigm change, which can otherwise be overwhelming.
You can complete and submit the assessment online (VBR Readiness Assessment) for analysis and recommendations. This is an overview of the assessment factors in each of the seven domains.
1. Care Coordination & Care Management
- Process in place for network providers to receive care management referrals from payers and other providers, and identify and track referral sources
- Communication tools in place to facilitate the integration of care teams within the organizations’ affiliated care delivery sites, including clear hand-offs of responsibility
- Arranges for periodic collaborative opportunities with providers, payers, and consumers to identify performance improvement initiatives
- Care management process to ensure that each consumer has at least one primary care wellness appointment annually
2. Clinical Management & Clinical Performance Optimization
Decision Support & Care Standardization
- System to determine early intervention and risk-adjusted care planning of consumers to ensure the most appropriate level of care
- Inclusion of the consumer and family in service and care planning activities and care plan documentation
- Standardized protocols that guide care management (i.e., clinical guidelines, medical necessity criteria, evidence-based practices, etc.) and include established timeframes for services, re-evaluation, and continuity of care between care settings
- Access to patient outcomes data to inform care management planning, access to the appropriate level of service, and referrals
- Performance metrics to assess provider specific results (i.e., provider profiling that may include average length of treatment, average cost per episode, number of re-hospitalizations, emergency room (ER) visits, adherence to medication, etc.)
Clinical Performance Tracking, Assessment, & Optimization
- Established process to assess outcomes and update practices to achieve greater fidelity to service quality indicators
- Established process to track and measure against key indicators related to cancellations and no-shows (by service, site, clinician, day of week, and time)
- Clinician and support staff access to dashboards and population health management analytics to assess outcomes and improve performance
- Reporting process to assess case-level data regarding readiness for change, intervention processes, extent of symptom resolution, and level of goal attainment, and to refine and revise care plans on an ongoing basis
Integration Of Physical Health, Behavioral Health, & Social Services
- Established referral and data sharing relationships with primary care and other physical health specialty providers in the community
3. Consumer Access, Service & Engagement
Consumer-Informed Access To Services
- Removal of technical, staffing, and procedural barriers of the consumer’s experience in accessing health information
- Clearly identified and convenient days and hours and locations of outpatient service availability (i.e., outpatient, telehealth, walk-in, etc.)
- Individualized care planning based on measurable goals to determine care outcomes and the need for ongoing treatment
Automated Consumer Service Functionality
- Access to services when needed (flexible, open, same day, consumer-focused scheduling)
Mobile Health Applications
- Use of technology with standardized clinical assessments (i.e., PHQ, SBRT, CAGE) to assist with diagnostics, clinical decision support, treatment, and cognitive function restoration
Consumer Wellness Support
- System to engage consumers in ongoing wellness support, including offering or facilitating access to disease management programs and classes
- Use of biometric screening to monitor basic health indicators (height, weight, BMI, blood pressure, waist circumference, fasting glucose/blood sugar, total cholesterol, HDL, LDL), and engage consumers in wellness strategies
Consumer Satisfaction Feedback Availability
- Survey tool used to gain consumer feedback about services? For example, obtaining an appointment, hours of operation, helpfulness of administrative staff, effectiveness of clinician, addressed to consumers satisfaction, etc.
Consumer Performance Metrics
- Claims-based outcome measures in place that track reductions in costly behavioral health care (re-hospitalizations within 30 days of discharge from inpatient psychiatric care, re-hospitalizations for medical conditions, follow-up after hospitalization for substance use disorder)
4. Provider Network Management
- Qualified accreditation in care coordination, health home or serving medically complex consumers (i.e., CARF, COA, Joint Commission)
- System to research, document and implement credentialing requirements of all payers
- Efficient workflow to obtain, review, and manage credentialing information for all clinicians, care managers, and care coordinators
- Automated process to monitor expiration dates of staff credentials and ensure renewal prior to expiration
- Contracting process in place to ensure provider network is contracted and considered in-network for all payer lines-of-business with separate rate schedules for each
- Process to recruit and assign clinicians and clinical teams based on capacity for effectiveness at individual client needs
5. Financial Management
Encounter Reporting
- Ability to electronically capture and report encounter data in the format and within the timeframe required by payers
- Quality assurance system in place to verify encounter data and ensure accuracy prior to submission
Value-Based Payment Capabilities
- Bill for services not included in value-based reimbursement agreements such as services that fall outside of bundled payment arrangements
- Established reporting system to reconcile capitation payments against enrollment data files
- Capability to process claims and pay providers fee-for-service who are not covered under the value-based payment agreement
- System can effectively identify consumers and providers who were part of a value-based reimbursement arrangement
- Established system to track capitated contract consumers receiving care from other providers outside of contract (leakage)
- Systems in place to understand and manage the cost of care provided under FFS, bundled payment, shared savings, shared risk and capitation, and role of the total cost of care (including medical, mental health, substance abuse, eating disorder, intellectual and developmental disabilities) to consumers in the service system
- Cost accounting system to calculate unit costs, target costs and identify the total cost of care
Financial Performance Monitoring
- Comprehensive set of key performance indicators that project short-term (3 to 6 months) and long-term (6 to 18 months) financial health
6. Technology & Reporting Infrastructure Functionality
Capacity To Collect Data
- Electronic Health Record includes additional functionality areas of population health data analysis, business intelligence, and care management in addition to service documentation and revenue cycle management
Capacity To Analyze Data For Population Health Management
- Data summarized in health registries for stratification consumer populations by diagnosis for risk-adjusted care planning (using diagnoses to identify high utilizer interventions)
Ability To Manage Value-Based Contracts
- Service utilization prediction model to assess resource needs and impact on financial resources
Ability To Exchange Healthcare Information
- Health information exchange agreements in place for key providers in the community (hospitals, ERs, physicians, specialty providers)?
- Automated technology to notify staff of inpatient or crisis services provided to consumers (ER visit, hospital admission, hospital discharge)
- Secure infrastructure in place and protocols in place that meets federal and state requirements, including HIPAA and HITECH
- IT staff have experience with systems integration, data conversion and managing expert resources to fill gaps in internal skills
Care Management Functionality
- Risk assessment tools to identify those consumers needing care management intervention plans
- Health care provider and social services referral database to facilitate care management referrals efficiently
Consumer Portal Functionality
- You have implemented a comprehensive consumer portal that includes helpful functionality—secure communication protocols, prescription refill requests, scheduling of appointments, access to forms, account balance and payment options
7. Leadership & Governance
Strategic Alignment Around Value
- Planning process that prioritizes resources based on mental health services that bring value to the community
- Adequate cash reserves to implement new payment methods and withstand changes in cash flow related to risk-based contracts
- Sufficient access to capital for infrastructure investment, or plan for accessing capital
- Established strong payer relationships and marketing plan to facilitate negotiation of new care models, payment innovations and data sharing agreements
- Board engaged in governance activities and knowledgeable about health care trends and strategic objectives
Culture Of Innovation
- Track record of successful implementation of new innovative programs, collaborative service arrangements, and value-based purchasing contracts
Workforce Adequacy
- Workforce culture, experience and capacity to innovate and adapt to the changing value-based payment business model, market and regulatory demands
- Compensation aligned with performance outcomes and strategic priorities
- Staff development function that identifies top talent, provides development opportunities and growth into highest level of functioning
- Process to assess staff competency on at least an annual basis and provide identified training focused on achieving actual improvements in performance