By Monica E. Oss, Chief Executive Officer, OPEN MINDS
As we look ahead to 2022–with more integration and more value-based care, the question is how do specialty provider organizations “fit” in an evolving service delivery and financing landscape. I think we’ll see a couple key developments in the next year. First, most consumers with mild and moderate conditions (of any type) will receive treatment services in a setting other than a traditional specialist provider organization–a retail setting, a primary care clinic, a digital-first provider organization, etc. Second, for consumers with complex needs, the value-based reimbursement model will move from the cost of behavioral health or specialty services to the total cost of care.
The challenge for specialty provider organizations is that there are additional organizational competencies needed to move from managing their own services to managing (and being incentivized based on) all the services a consumer receives. One path to achieving this performance alignment (both clinical and financial) is for the health plan to supplement the provider organization infrastructure. Even with the health plan’s infrastructure, provider organizations must have the technology and staff expertise to take advantage. We heard more about how that type of payer/provider collaboration can work in the session “P” Is For Payers, Priorities, Partnership … & Platforms at the OPEN MINDS 2021 Health Plan Partnership Summit. Michelle Berthon, Director of Provider Enablement Operations and Integrated Behavioral Health Homes at Optum, and Kimberly Macakiage, Director of Practice Management Accountable Care and 1115 Medicaid, Waiver Projects at Integral Care, presented a case study of a model SMI health home initiative in Texas. The session, moderated by Netsmart’s Neal Tilghman, their General Manager of Integrated Care, provided a deep dive into common health plan needs, ways to measure and communicate metrics, and the role of data in building trust in relationships.
Established in 1967 as a one-location facility, Integral Care now provides over 529,000 services to over 29,000 individuals each year at over 45 locations. As a certified Community Behavioral Health Clinic (CCBHC), Integral Care emphasizes recovery, wellness, and physical-behavioral health integration. Starting in November of 2020, Optum created a relationship with Integral Care to provide integrated behavioral health home services in the Austin metropolitan area. Integral is responsible for providing referrals to community and social support services, care coordination, comprehensive care management, patient and family support, health promotion, and transitional care from a 24-hour facility. For service reimbursement, they receive a unique payment arrangement consisting of a case rate beyond fee-for-service, and a shared savings incentive to encourage patient engagement in the community and overall health outcome improvement.
What is unusual about the model is the level of technical assistance and support Optum provides to Integral Care to help manage the total health care needs for consumers. Optum provides a wide range of actionable data and data tools–a portal to confirm eligibility and access data, shared care management insights, a consolidated data set, and the analytics to drive action and monitor performance. Ms. Macakiage emphasized the role of data in the model, “to be able to look at data as a provider and see how someone performs outside of your system has been a game changer in terms of what we are able to do.” But there are also unique features to this model. Ms. Berthon noted that “While the tools, platforms, and technology are all very nice, what is even more differentiating is to have a provider organization walking with you, side-by-side, helping to implement these innovative programs.” Optum’s “secret sauce” for this model involves utilizing Practice Enablement Consultants–licensed clinical professionals with expertise in behavioral health, quality improvement, and integrated care delivery who assist provider organizations with implementation and ongoing management of the program. Integral Care’s differentiator is its population health methodology in which data analysts can digest and present actionable data to inform daily clinical decisions and its committed care managers who can effectively bond with members.
So, what makes the “ideal” health home provider partner? Ms. Berthon spoke of four important characteristics that Optum looks for in provider organization partners. First, a trauma-informed care approach that resonates across the organization. Second, a Stages of Change orientation that allows organizations to tailor individual interventions. Thirdly, intentionality in addressing health disparities/inequities and social determinants of health. Last, but not least, a performance improvement culture that supports the organization’s use of data to drive decisions and practice transformation. Although these four characteristics are notably important, Ms. Berthon noted that having a deeply collaborative partnership between the MCO and provider organization was preeminent for success, and without it, implementing effective and transformational health home programs becomes increasingly unfeasible.
This relationship between Optum and Integral Care illustrates the changing alignment of not only financial incentives but also operating systems in the health and human service landscape. As health plans and provider organizations reposition as “payviders”, this type of model with shared data and financial incentives will likely be more common.