www.openminds.com 163 York Street, Gettysburg, Pennsylvania 17325 Phone: 717-334-1329 - Email: [email protected]June 2, 2016 Presented by: Robert Teitt, Vice President of Technology & Business Development, Askesis Monica E. Oss, Chief Executive Officer, OPEN MINDS Quality Mental Health Care In A Value-Based Environment: Keeping The Vision Beyond Mental Health Month
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Quality Mental Health Care In A Value-Based Environment
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Current Medicare ACO ModelsMedicare Shared Savings Program (MSSP) Under this program, ACOs have the choice of three different risk tracks. The MSSP is one of two ACO models that CMS is still accepting new ACOs.
Next Generation ACO Model The Next Generation ACO is similar to the pioneer model ACO and requires ACOs to take on a greater amount of risk than the MSSP program. 21 ACOs under this model begin operating January 1, 2016. A second round of ACOs will begin operation on January 1, 2017.
Telehealth expansion permitted: ACOs may provide telehealth services to all beneficiaries regardless of where they reside. Currently, CMS only allows telehealth to be provided to beneficiaries who live in rural areas.
Post-discharge home visits permitted: Within 10 days of beneficiary discharge from an inpatient facility, providers under the general supervision of the ACO may bill for “incident to” services provided at the beneficiary’s home.
SNF 3-day waiver rule: Beneficiaries may be directly admitted to a SNF without a 3-day inpatient stay, as currently required by Medicare.
ACOs Started In Medicare But Widely Adopted By
Health Plans
There are now over 800 public and private ACOs in all 50 states
Use Of Medical Homes & Health Homes In MedicaidMedical homes/health homes manage the health of a population, typically receiving PMPM reimbursement with performance incentives. Medical Home, aka patient-centered
medical home (PCMH), coordinates the overall health care needs of a broad population
Health Home, defined in Section 2703 of ACA, offer coordinated, team-based care to individuals within a specific population – usually with multiple chronic health conditions including mental health and substance use disorders. * Alabama, District Of Columbia, Idaho, Iowa, Kansas, Maine,
Maryland, Michigan, Missouri, New Jersey, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Dakota, Vermont, Washington, West Virginia, Wisconsin.
The First Big Question – What Does This System Change Mean For Quality? We’ve redefined quality. . . quality of value-based reimbursement is monitoring access/underutilization, experience, and health outcomes1. Consumer sovereignty in an era of rising
consumer payments2. The trickle down effect of health plan ratings
Consumer Sovereignty. . . .a policy which assumes that the best profit will come from providing customers with the best products and best customer service at the lowest possible price. . . How do health and human service organizations use “consumer sovereignty” to remake their services?
– The first step is to understand who the consumers are.
– Then, how they use services and why.– And, finally, to understand what they value
The Changing World of Health Plans• Medical loss ratio limitations• Smaller subsidies for plans on health exchanges• Downward pressure on rates and increased
competition (from each other and from ACOs)• Focus on human service coordination for consumers
with complex needs• Consolidation to gain scale in operating costs• Backward integration – via acquisitions and
gainsharing reimbursement arrangements with providers
Issues For County Planning Changing ‘safety net’ role in states that have expanded
MedicaidMore demand for uncompensated services in states that have
not expanded services Challenges for units of government that deliver direct
consumer services – collaboration, consumer experience, risk assumption, technology investments, unit cost management, etc. Need to develop preferred models for collaboration – with
‘defined boundaries’ -- between health (medical/behavioral) and social service systems
Considerations For CMHCs & FQHCs1. Creating model for participation in vertically integrated health
systems -- both delivering and financing care
2. Creating model for delivering ‘seamless’ consumer experience for integrated behavioral/primary care experience – that meets consumer convenience expectations
3. Capitalizing expenditures for new technology and systems
4. Privatization of the medical home/health home role
5. Effects of possible assumption of targeted case management role by Medicaid health plans
6. Effects of the creation of new primary care models by Medicaid health plans
7. Disruptive effects of widespread telehealth – for both behavioral consultation and for primary care
8. Diminishing ‘direct’ funding as more of the population is insured
More unpaid
demand for
services in states that have not expanded Medicaid