Building An Infrastructure For Innovation: An Executive ... · The CareLogic EHR and CareLogic Analytics Suite provides multiple options for organizations to meet the clinical, financial,data,

www.openminds.com n 15 Lincoln Square, Gettysburg, Pennsylvania 17325 n 717-334-1329 n [email protected]

Building An Infrastructure For Innovation: An Executive Guide For A Value-Based

Market

Ken Ca r r, Sen io r Assoc ia te , OPEN MINDS

© 2018 OPEN MINDS

CareLogic®Analytics

TransformYour Information Into Meaningful Insights andActions

Qualifacts is proud to partner with OPEN MINDS in support of today’s presentation.

The CareLogic EHR and CareLogic Analytics Suite provides multiple options for organizations to meet the clinical, financial, data,

and reporting needs necessary to thrive in a value based market.

Connect with a Qualifacts team member after the session to schedule a personal tour of CareLogic Analytics Suite.

© 2018 OPEN MINDS

I. The Drivers Shaping The Movement To Value-Based Contracting The

Value-Based Reimbursement Business Model

II. The Value-Based Reimbursement Business Model The Role Of

Population Health Management In A Data-Driven Organization

III. The Key To Value-Based Contracting Success Is Managing

Performance The OPEN MINDS Value-Based Reimbursement

Management Readiness Assessment

IV. Infrastructure Competencies To Success In Value-Based Contracting

3

© 2018 OPEN MINDS© 2018 OPEN MINDS

I. The Drivers Shaping The Movement To Value-Based Contracting

4

© 2018 OPEN MINDS

The Drivers Of The Changing Service Delivery Landscape

5

Mental Health & SDoH Drive Integrated & Coordinated

Care

Changing Reimbursement

New Technologies

Emerging Consumerism

Changing Sustainability

Drives Consolidation

The Landscape

© 2018 OPEN MINDS

Acute care

Post-acute care

Primary care

Long-term care

Social and

human services

Facility-based Community-based Home-based

Payers & Health Plans Looking To “Care Coordination” & “Integration” To Reduce Costs – By Shifting Service Model

6

The Landscape

© 2018 OPEN MINDS

Changing Provider Reimbursement Models To Support “Integration”

Of the 38 states with Medicaid managed care, 22 require the Medicaid health plans to implement VBR with provider organizations At least 11 states have Medicaid ACOs

81% of Medicaid health plans have P4P FFS payments for behavioral health organizations

47% of Medicaid health plans have bundled payments for specific acute episodes

Nationally, specialty provider organizations with VBR revenue: 41% of primary care organizations

33% of behavioral health organizations

34% of child and family services organizations

14% of I/DD and LTSS organizations

7

The Landscape

© 2018 OPEN MINDS

Value-Based Reimbursement Here To Stay Because...

Political and competitive pressure on payers –

federal government and employers

Downward price pressure on health plans

Pressure on health plan medical loss ratios

The success of ‘some’ ACOs

The early findings of the Medicare bundled rate

initiative

Return to fee-for-service not feasible –

only “lever” in FFS is to reduce rates

8

Consumerism

Technology

adoption

Value-based

reimbursement

“Integration” for

improved cost and

quality

The Landscape

© 2018 OPEN MINDS

Shifting Role Of Technology In Health & Human Services

Administrative Tool

Compliance Requirement

Platform For Competitive Advantage

Compliance focus the past ten years

– Result - less focus on usability and clinical effectiveness

From “cost” to “investment”

From “administrative management” to “imbedded in service lines”

– Essential for competitive advantage – and market positioning – over the next five years

9

The Landscape

© 2018 OPEN MINDS

The Four-Stage Evolution Of Service Lines In Health & Human Services

Stage I: The Transition To (Semi) Competitive Market

Stage 2: The Integration Phase

Stage 3: The Value-Based Reimbursement Phase

Stage 4: The Tech Leverage Phase

© 2018 OPEN MINDS

The Value Of Investing In Technology

Competitive Advantage Driven By Value To Payers &

Consumers

Product

BenefitBrand

Equity

Marketing

Benefit

Price= Value

© 2018 OPEN MINDS

Strategic Quality Concept

Invest in “quality improvement” that differentiates you

from competitors – and customer is willing to pay for

the differential cost

Requires an understanding of:

Customer perceptions

Customer segmentation

Competitive offerings

Customer perceptions of competitive offerings

Price elasticity

Eight Dimensions Of “Quality”

Performance

Features

Reliability of service system

Conformance to standards

Durability and length of effect

Serviceability and customer experience

Aesthetics

Perceived quality

© 2018 OPEN MINDS

Optimizing Organizational

Performance, Care

Coordination & Population

Health Management

Getting The Necessary

Data

Technology Infrastructure To Support Performance Management

Electronic

health records

Health information exchange

and data aggregation

Care

coordination

platforms

Advanced population analytics

and clinical decision support

Performance

monitoring and

management tools

Consumer

segmentation

and health risk

stratification

Consumer referral trackingPatient registries

13

© 2018 OPEN MINDS

Reducing Service Cost

Engaging Consumers

Technology Infrastructure To Optimize Value Of Consumer Care

Patient portals,

websites, and web-

based consumer tools

Automated

consumer outreach

Telehealth and

telemedicine

Remote

monitoring and

distributedservice platforms

Tech improving

admin efficiencies

of staff

Tech-enabled

treatment

services

14

© 2018 OPEN MINDS

Leverage Of Technology To Reinvent Services Key To Long-Term Sustainability

1. Personalization of consumer treatment

2.More effective care coordination

3. Transparency in measurement of “value”

Telehealth and virtual

consultation changing

geographic market

boundaries for services

Smartphone and other

technologies for inexpensive consumer-

directed disease

management

Health information exchange provides data exchange and creates

‘big data’ for better consumer service

planning

New treatment technologies have

changed the options for consumers

15

Technologies permit task shifting to less expensive

staff


II. The Value-Based Reimbursement Business Model

16

© 2018 OPEN MINDS

The Shifting Reimbursement Market

A Change In Focus:

Reducing Costs While Delivering &

Demonstrating Value

A Change In Methods:

Managed Care & Value-Based Purchasing

© 2018 OPEN MINDS

Business Model Transition For Provider Organizations

Payer Policy

Pay-For-Cost/Volume

Payer Policy Pay-For-Value

Business Model

What is paid for is

good for the

consumer and

doing more is the

business model

Business Model

Giving the

consumer (and

their payer) good

outcomes at a low

cost, conveniently

A revolution in

performance

management

required

Focus on achieving

outcomes and

managing risk

Focus on maximizing

price and managing

volume

© 2018 OPEN MINDS

Capitation + Performance

-Based Contracting

CapitationShared RiskShared Savings

Bundled & Episodic

Payments

Performance-Based

Contracting

Fee-for-service

Transition Of Payment To Provider Organizations From Volume To Value

Compensation Continuum By Level Of Financial Risk

No Financial Accountability Moderate Financial Accountability Full Financial Accountability

Passive Involvement Provider Engaged Provider Active In Management Providers Assumes

Accountability

Management Via 100% Case By

Case External Review

Internal Ownership Of Performance

Using Internal Data Management

Small % Of Financial Risk Moderate % Of Financial Risk Large % Of Financial Risk

© 2018 OPEN MINDS

45%

30%

23%21%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

PFP FFS Capitation for specificservices

Capitation for carecoordination

Case rate or bundledrate

Distribution Of VBR Models Is Changing

20

*Note provider organizations could select that they were participating in more than one type of VBR arrangement

Provider Organizations Participating In APMs, By Model Type, %, 2019

© 2018 OPEN MINDS

Key Effects Of Moving From FFS To Managed VBR

Focus On Outcomes

Create A Data-Driven Culture

Data, Analytics, Change

Management

Implement Effective

Technology

Manage Unit Costs &

Financial Risk

21

© 2018 OPEN MINDS

22%

22%

23%

32%

36%

Access to caremeasures

Patient/consumersatisfaction

Emergency roomutilization

Readmission rates

Follow-up afterhospitalization

Follow-Up After Hospitalization & Readmission Rates Are The Most Popular Measures For Determining Performance

22

Top Five Performance Measures In Value-Based Contracts, %, 2019

© 2018 OPEN MINDS

Top Five Performance Measures In Value-Based Reimbursement Contracts With Specialty Provider Organizations, By Market, %, 2019

23

Top Five Performance Measures By Market, %, 2019

Behavioral Health Child Services I/DD & LTSS Primary Care

1. Follow-up after

hospitalization – 41%

2. Readmission rates –

33%

3. Access to care

measures – 27%

4. Patient/consumer

satisfaction – 26%

5. Emergency room

utilization – 24%


19%

2. Follow-up after


3. Emergency room

utilization – 13%

4. Access to care

measures – 10%

5. Patient/consumer


1. Use of evidence-

based care protocols

– 24%

2. Follow-up after



21%

4. Patient/consumer


5. Emergency room

utilization – 14%


58%

2. Follow-up after


3. Emergency room

utilization – 46%

4. BMI assessment –

46%

5. Annual flu vaccine –

42%

© 2018 OPEN MINDS 24

17%

19%

19%

23%

25%

39%

Risk management capabilities

Finding the experienced managers to manageperformance-based reimbursement

Managing care coordination for consumers

Lack of clarity about performance requirementsfrom payers

Building needed IT infrastructure

Data management and reporting

% of Organizations

Typ

es O

f C

ha

llen

ge

s

Top Five Challenges To Managing Value, %, 2019

Specialty Provider Organization Executive Teams


III. The Key To Value-Based Contracting Success Is Managing

Performance

25

© 2018 OPEN MINDS

Manage Performance In All Functions Of The Organization

Customer Experience

Clinical Performance

Compliance

Financial Sustainability

Marketing & Business

Development

Fundraising & Grants

Payer Contract

Performance

Employee Experience

Technology & Data

Analysis

© 2018 OPEN MINDS

Focus On Four Types Of Outcomes For VBR Success

The New Value

Assessment

Contract-Specific Performance

Measures

Routine Services and Transactions

Great Customer Service

Cutting Edge Expertise

© 2018 OPEN MINDS

1. Contract-Specific Performance Measures

The floor for success

Requires a payer perspective and a consumer

perspective of ‘value’

Reflect outcomes that are the costliest to the

payer

Reflect outcomes that the payer is accountable

to achieve to receive maximum reimbursement

Mandated Health Home

Performance Measures

Adult body mass index assessment

Controlling high blood pressure

Screening for clinical depression

and follow-up plan

Follow-up after hospitalization for

mental illness (7 and 30 day)

Initiation and engagement of

alcohol and other drug (AOD)

dependence treatment

Plan all-cause readmissions

Prevention quality indicator (PQI)

92: chronic conditions composite

Ambulatory care: emergency

department visits

Inpatient utilization

Nursing facility utilization

10 National Health Home

Measures

NCQA HEDIS Measures

CMS STARS Measures

Most Common Health Plan

Contract Measures

Your Specific Health Plan

Contract Measures

© 2018 OPEN MINDS

2. Routine Services & Transactions

Consumer sovereignty – a business philosophy assuming the best profit will

come from providing customers with the best products and best customer

service at the lowest possible price

The Amazon

Doctrine –

above all else,

align with

customers.

“Win when they

win. Win only

when they win.”

Search Engine Ranking &

Optimization Scores

InquiriesInquiry

Response Time

Inquiry Conversion

Rates

Time To Appointment

Service Rates

© 2018 OPEN MINDS

3. Customer Service

Providing service that creates ‘passionate advocates’ of your brand

Designing workflow from a consumer experience perspective –

preventing consumers from “feeling like they are simply another

transaction”

Developing a written

service strategy to

ensure consistency of

consumer experience

– and cultivate

consumer loyalty

Net Promoter Score

Customer Satisfaction

Customer Experience Monitoring (“Mystery

Shopper”) Results

Online Reputation

© 2018 OPEN MINDS

4. Clinically Cutting Edge – A Consumer Advisor On Emerging Science

Can you be replaced by an online clinical decision support tool?

Understanding the new science in your area of specialization

Mastering the

new technologies

– and integrating

them into your

service array

(whether you

provide them or

not)

Consistency In ‘Treatment Model’ -Lack Of Unexplained

Variability

Time To Evaluation/Adoption Of

New Treatment Technology

© 2018 OPEN MINDS

Top Five Key Performance Indicators

32

Domain Indicator Goal Review Parameters

Customer

ExperienceNet Promoter

Score

Assessment of customer

satisfaction and referral

development

Response to question about likelihood of

recommending our organization to friends and family

members; Monthly - Total, By Market, By Service

Line, YTD, Previous Year

Employee

ExperienceRevenue lost due

to vacancies

Identification of employee

satisfaction issues impacting

turnover and organizational

sustainability

Average revenue times time open for unfilled

positions; Monthly - Total, By Market, YTD, Previous

Year

Financial

SustainabilityA/R (days in

receivables)

Assessment of future cash flow and

identification of payer issuesTotal A/R divided by average daily charges; Monthly -

Total, By Market, By Service Line, YTD, Previous

Year

Clinical

Performance

ER utilization

(service lines

TBD)

Effectiveness in sustaining recovery

by providing timely, nonacute

services

Monthly - Total, By Market , By Service Line, YTD,

Previous Year – will require data sharing and/or

integration

Technology &

Data AnalysisNumber of report

requests and time

to complete

Organization use of analytics;

analytics resource adequacy and

effectiveness

Count of requests submitted and number of work

days from request to completion; Monthly - Total, By

Market, YTD, Year over year

Customer

ExperienceDays to

appointment

Assessment of customer

satisfaction and service quality

Monthly, Total, By Market, By Service Line, YTD,

Previous Year


IV. Infrastructure Competencies To Success In Value-Based Contracting

33

© 2018 OPEN MINDS

I. Provider Network Management

II. Clinical Management & Clinical Performance Optimization

III. Consumer Access, Service, & Engagement

IV. Financial Management

V. Technology & Reporting Infrastructure

VI. Leadership & Governance

Six Domains In OPEN MINDS Model For Assessing Value-Based Reimbursement Management Readiness

© 2018 OPEN MINDS

IV. Four Key Competencies Of Financial Management

1. Revenue Cycle Effectiveness

2. Encounter Reporting

3. Value-Based Payment

Capabilities

4. Financial Performance Monitoring

© 2018 OPEN MINDS

1. Revenue Cycle Effectiveness

Focus:

Ability to align operational and

financial processes to assure adequate cash

flow

Key Competencies For Success

Effective processes for

reconciliation of authorizations and

payment verification to credentialed

provider organizations

Ability to submit invoices to payers

for services delivered under value-

based reimbursement agreements

© 2018 OPEN MINDS

2. Encounter Reporting

Focus:

Ability to capture, analyze, and report

granular utilization data to payers and to internal teams for

management


Ability to electronically capture and

report reliable encounter data in the

format and in the timeframe

required by payers

Ability to analyze encounter data to

manage service outcomes and

utilization

Aggregation of encounter data to

manage value-based

reimbursement agreements

© 2018 OPEN MINDS

3. Value-Based Payment Capabilities

Focus:

Ability to track manage contractual outcomes

and payments


Ability to report on actual

performance data – outcomes and

financial performance – against

budget and against contractual

targets

Ability to bill for multiple types of

value-based reimbursement models

© 2018 OPEN MINDS

4. Financial Performance Monitoring

Focus:

Ability to monitor actual financial results against contracts, budgets, and

forecasts


Ability to report incurred but not

reported (IBNR) liabilities

Ability to monitor service utilization and

costs and reconcile to service and

revenue projections

System to link population health

management and value-based

contracting strategies to resources

planning and reporting

Comprehensive set of key performance

indicators for short-term and long-term

financial health

© 2018 OPEN MINDS

V. Seven Key Competencies Of Technology & Reporting Infrastructure

1. Capacity To Collect Data

2. Capacity To Analyze Data For Population Health

Management

3. Ability To Manage Value-

Based Contracts

4. Ability To Exchange Healthcare Information

5. Care Management Functionality

6. Consumer Portal

Functionality

7. IT Performance Monitoring

© 2018 OPEN MINDS

1. Capacity To Collect Data

Focus:

Technology infrastructure to collect

data strategic in identifying health

needs of the population of consumers served


EHR core functionalities fully

implemented

Structured data collection around

assessments, diagnoses, and services

Workflows and processes to ensure

data integrity

Ability to collect data at the time and

source of service provision

© 2018 OPEN MINDS

2. Capacity To Analyze Data For Population Health Management

Focus:

Ability to perform strategic analysis of

data for risk stratification and care

management


Development of or access to consumer

data registries

Deployment of data analysis tools

Implementation of risk stratification

strategies

Ability to integrate multiple sources of

data

© 2018 OPEN MINDS

3. Ability To Manage Value-Based Contracts

Focus:

Ability to track performance metrics, submit invoices, and

maximize performance of value-based

contracts


EHR functionality that meets billing

requirements for value-based

purchasing models

Integration of clinical, operational and

financial data

Unit costing and cost accounting

capabilities

Predictive modeling and forecasting

capabilities

© 2018 OPEN MINDS

4. Ability To Exchange Health Care Information

Focus:

Ability to exchange clinical and financial

information with other health care provider

organizations


Health information exchange

agreements with key providers

Secure infrastructure, policies and

workflows that comply with HIPAA and

HITECH

Service notification agreements,

automation and processes with other

providers

© 2018 OPEN MINDS

5. Care Management Functionality

Focus:

Ability to manage eligibility, coordination

of benefits, inquiries/referrals,

decision support, care authorization, care coordination and

utilization management


Automated risk assessment tools

Redesigned workflows to maximize

care management technology

Provider referral database to aid in care

matching and management

© 2018 OPEN MINDS

6. Consumer Portal Functionality

Focus:

Ability to provide service data, resources and interaction options

with consumers through the EHR


Convenient, secure access to

personal health information through

the internet

Ability to access staff and services

through technology

Access to forms and account

payment functionality

© 2018 OPEN MINDS

7. IT Performance Monitoring

Focus:

Ability to monitor actual IT outcomes against

established goals


Established key performance

indicators

Ability to generate real-time

reporting on performance under

value-based reimbursement

arrangements


Questions & Discussion

48

© 2018 OPEN MINDS

CareLogic®Analytics

TransformYour Information Into Meaningful Insights andActions

Qualifacts is proud to partner with OPEN MINDS in support of today’s presentation.

The CareLogic EHR and CareLogic Analytics Suite provides multiple options for organizations to meet the clinical, financial, data,

and reporting needs necessary to thrive in a value based market.

Connect with a Qualifacts team member after the session to schedule a personal tour of CareLogic Analytics Suite.

Turning Market Intelligence

Into Business AdvantageOPEN MINDS market intelligence and technical assistance helps over 550,000+

industry executives tackle business challenges, improve decision-making, and

maximize organizational performance every day

www.openminds.com n 15 Lincoln Square, Gettysburg, Pennsylvania 17325 n 717-334-1329 n [email protected]

Documents

Building An Infrastructure For Innovation: An Executive ... · The CareLogic EHR and CareLogic Analytics Suite provides multiple options for organizations to meet the clinical, financial,data,