On October 19th, 2017, stakeholders from across Texas and beyond gathered for the annual policy summit that take place in conjunction with the CFHA Annual Conference. This year the policy summit focused on value-based payments and was supported by several organizations including The Meadows Foundation, Mental Health America of Greater Houston, Health Management Associates, and CFHA.
Neftali Serrano, the CFHA Executive Director, opened the summit saying “There are two bottlenecks in our field right now: payment reform and workforce development. You need a trained and sustained workforce and then payers who feel confident in what they are funding”. Alejandra Posada, Chief Program Officer of Mental Health America of Greater Houston, also opened by saying “CFHA met in Austin five years ago when we were just starting many initiatives. We have indeed made progress since then”.
Joan Henneberry, vice president of Health Management Associates, set the stage with a national perspective of value-based payments. “We do this work because we know it costs the system more to care for patients with medical and behavioral health problems. We do this because patients can take better care of themselves and their chronic diseases when mental health is addressed”. Much of the progress is happening in the public sector.
She argues that now is a great time for payment reform and that many states are experimenting with multiple models. “Even private sector payers are beginning to have their “aha” moments with integrated care”. However, many states worry that health plans are not taking on enough risk and will continue to use fee-for-service (FFS) models without helping providers change delivery models. The solution is for health plans to contract with community organizations and high value providers that know the community and needs of patients.
“So, what are value-based payments (VBP)?” she asks. There is a long continuum and it depends on how much risk an organization wants to take. In Denver, Joan’s group started with a per-member-per-month (PMPM) capitation model for pediatric care with specific standards. That was an easy place to start. Where she thinks this is all moving is toward a varying rate of reimbursement. “If you as a practice do not embrace the Triple Aim in the future, then you may get a lower reimbursement rate from your payer.”
But what if providers don’t want to participate in VBP? Joan cites a 2016 physician survey that found that even though 80% of physicians did not support a change in reimbursement, many did admit that the FFS model does not offer value. Moreover, 71% said they would participate in VBP if offered financial incentives but that they don’t want to be held accountable for outcomes they can’t control. The survey even suggests that hospitals are willing to try VBP. “It’s a little harder to engage hospitals, but not impossible.”
Finally, Joan identifies some states that are succeeding with shared a savings approach (Colorado, Oregon, Vermont). However, these states learned that you cannot just do one pilot project after another. The change needs to be systemic but scaled down to the needs of each clinic. Maryland has moved toward an “All Payer” model by setting payment rates for Medicare in addition to regulating the states market. As a result, 95% of hospital revenue is in a global budget with all 46 hospitals joining into the change.
Ellen Breckenridge, faculty associate at the University of Texas School of Public Health, continued the summit by sharing results from a large study of integrating medical services into community mental health centers. This study was made possible by the Section 1115A waiver and the Delivery System Reform Incentive Payment (DSRIP) initiatives in Texas. Ten sites participated although a few struggled to report final results due to data restrictions.
There were several challenges for the participating sites: some did not have shared medical records; four had tried integration in the past but without success; four sites did not have a physician for the first four months of the study (it was difficult to find willing and able physicians); managed care contract delays prevented billing for services; and the patient population was very poor.
Despite these challenges, the sites were able to provide medical services for thousands of patients. By the end, all ten sites were using team-based care, eight were using shared records, warm handoffs, and morning huddles, and seven were sharing treatment plans and organizing all care onto the same floor. Staff and patient feedback was very positive. Staff believed the care was now more holistic and patients felt more comfortable and healthy. Screening rates and health outcomes improved dramatically while hospital encounters and hospital stays dropped by 18% and 32%, respectively. Sustainability is a concern, though, since 62% of the patient population does not have insurance.
Heidi Schwarzwald was the next speaker and described the use of VBPs at the Center for Children and Women (CCW), part of the Texas Children’s Health Plan. The CCW uses a capitated, 100% risk model with comprehensive, team-based services including behavioral health integration. Since offering integrated care, the CCW has excelled in ADHD stimulant initiative and maintenance as well as 7-day psychiatric hospitalization follow-up. We are having success, she remarks, but we are only reaching a small portion of all patients in the entire health plan. The next step is to expand even farther.
All the previous speakers including Ernest Buck, Chief Medical Officer from Driscoll Health Plan, Lisa Kirsch, Senior Policy Director at the Dell Medical School, and Dawn Velligan, from UT Health San Antonio, joined in a panel discussion that included topics ranging from incentivizing small, rural clinics to participate in VBPs to using peer specialists and community health workers to training all stakeholders to buy into VBP rationale. All panelists agreed that progress is being made, but that we need more evidence to make smart decisions.
The final speaker was Andy Vasquez, Deputy Associate Commissioner for Texas Health and Human Services Commission, who presented an impressive roadmap for VBP in Texas. This roadmap details numerous VBP initiatives at the state level focused on quality and efficiency to achieve the Triple Aim. Most are underway, but many still in development. The roadmap is too large to summarize here. So, I will refer the reader to read the attachment below.
Finally, the policy summited ended with a number of small groups tackling big issues like sharing health data between different systems, building capacity and technical assistance for integration, and specific policies needed for making VBPs easier for all levels of care. Look in the future for a final report from the Mental Health America of Greater Houston with specific recommendations for how to prepare your state for value-based payments.
| Matt Martin, PhD, LMFT, is clinical assistant professor at the Arizona State University Doctor of Behavioral Health Program. He is also blog edit for the Collaborative Family Healthcare Association. Please contact Matt if you want to contribute to the blog. |
