Preventing Crucial Legislative Voids and Regulatory Gaps in Oregon House Bill 3725
Mentor Research Institute
March 1, 2025
A Discussion Paper
Definitions For Healthy Contract Discussion
https://www.mentorresearch.org/healthy-contracts-bill-definitions
Summary
House Bill 3725 (HB 3725) introduces some new oversight mechanisms but inadequately protects mental and behavioral health providers from unlawful contracting practices, market manipulation, and coercive health plan policies.
Based on a documented complaint, contract analyses, and industry research, MRI finds that while HB 3725 may strengthen protections for some mental and behavioral health providers it fails to close crucial enforcement gaps that threaten patients, stakeholders, provider practices and public health. The named health plan relies heavily on funding from federal and state taxpayers.
If the loopholes are not addressed, independent practices may be systematically phased out, leaving mental and behavioral health providers with little choice other than to become employees of health plans or large corporations.
Without the reforms proposed in this discussion, the market will shift irreversibly, cementing a system where health plans control both care delivery and reimbursement, eliminating provider autonomy and reducing patient choice and access.
HB 3725 does not adequately protect minority and underserved populations.
By incorporating 5 crucial provisions, HB 3725 can become the strongest health plan accountability law in the U.S., ensuring fairness, transparency, and protections for corporate, and independent mental health practices.
MRI’s concerns about the regulatory inadequacy of HB3725 are supported by its library of research, legislative analysis, ethical considerations, and case example discussions, available at https://www.mentorresearch.org/healthy-contracts-categorized.
This document is offered as a discussion paper for education and legislative purposes. While HB 3725 includes positive provisions such as reporting requirements, MRI asserts that without additional enforcement mechanisms, the bill will fail to prevent ethical violations, fraud, bad faith contracting, and other current abuses in Oregon’s health system.
To strengthen HB 3725, MRI recommends five key amendments, including: (1) independent internal health plan or external oversight boards, (2) whistleblower protections, (3) contract transparency mandates, (4) secure online confidential reporting, and (4) stronger antitrust enforcement scrutiny.
These recommendations are based on findings outlined in MRI’s research see References below:
When Denial Becomes Deadly
This article examines the public outcry over health insurance claim denials following the killing of UnitedHealthcare CEO Brian Thompson. It highlights growing frustration with insurers prioritizing profits over patient care, with prior authorization delays and high claim denial rates worsening health outcomes. The piece also explores the role of algorithms in increasing denials and the financial burden placed on patients. Social media reactions reflect deep-seated anger toward the healthcare system, emphasizing the urgent need for reforms to ensure fair and transparent insurance practices.
https://www.mentorresearch.org/when-denial-becomes-deadly
Providers and policymakers must advocate for meaningful accountability and enforcement mechanisms to ensure that HB 3725 achieves its intended goals. HB 3725 creates loopholes which allow health plans and the OHA to misuse taxpayer funds and unlawfully replace independent practices with employer and health plan owned practices. If this loophole is addressed, independent practices will be systematically phased out. Small employer owned practices will by consumed by large corporate owners. By the time reforms are implemented, the market will have shifted irreversibly, cementing a system where health plans control both care delivery and reimbursement, eliminating provider autonomy and reducing patient choice.
HB 3725 introduces new oversight mechanisms, reporting requirements, and contract transparency rules, while it fails to prevent health plan fraud, coercion, bad faith contracting, unethical behavior, and market manipulation. HB 3725 is an example of “solutionism.”
Solutionism: Oregon Health Authority’s Value-Based Payment (VBP) Roadmap
The article critiques the Oregon Health Authority's (OHA) Value-Based Payment Roadmap, arguing that it exemplifies "solutionism", the oversimplification of complex healthcare issues through technical fixes without addressing underlying systemic problems. It contends that the OHA Roadmap's emphasis on value-based contracts overlooks crucial concerns such as contract transparency, equitable financial risk distribution, violations of law, and the administrative burdens placed on providers. The article warns that without addressing these foundational issues, the VBP Roadmap may lead to unintended consequences, including provider burnout, reduced care quality, and the perpetuation of existing power imbalances in the healthcare system.
https://www.mentorresearch.org/the-oregon-health-authoritys-valuebased-payment-vbp-roadmap-as-an-example-of-solutionism
Allegations of Bad Faith, Fraud and Antitrust Violations by Moda Health Submitted to the Oregon Health Authority - Whistleblower Complaint
This paper discusses whistleblower allegations against Moda Health, including claims of bad faith contracting, fraud, and antitrust violations. It details how Moda allegedly uses deceptive contract terms and restrictive policies to limit competition and undermine independent practices. The article also compares these practices with legal standards to highlight potential breaches of antitrust and healthcare regulations, supporting the need for legal intervention.
https://www.mentorresearch.org/whistleblower-complaint-allegations-of-bad-faith-fraud-and-antitrust-violations-by-moda-health
Providers must advocate for accountability, investigative, and enforcement power. MRI believes the Oregon Health Authority has ignored complaints and requests for legislative guidance, legal protections and supports which would prevent the unlawful foreclosure of independent practice.
In 2024, the Independent Mental Health Practices Alliance (IMHPA) Filed a Complaint Against Moda Health.
The complaint alleges and provides evidence of bad faith, and illegal contracting practices including fraud and violation of antitrust.
The complaint was filed with the Oregon Health Authority (OHA), the Department of Consumer and Business Services (DCBS) and the Department of Justice (DOJ). IMHPA discovered that there is absolutely no way under Oregon Law to enforce accountability for complaints filed by independent mental health professionals.
House Bill 3725, in its current form:
Will not hold health plans accountable for behavior that undermines independent practice.
Does not hold health plans accountable for violations of civil and criminal law, violations which independent practices cannot afford to challenge in court.
Offers no mechanisms for providers to report or investigate evidence or allegations of violation of laws.
Leaves in place the current situation, in which commercial health plans can break the law, and care providers are expected to report allegations of criminal conduct to the very people committing the crime.
Exposing Loopholes: How Health Plans Can Escape Accountability for Violations of Civil and Criminal Law
This discussion document examines how health plans can exploit regulatory gaps in Oregon to engage in unethical practices with minimal risk of consequences. Despite efforts by organizations like Mentor Research Institute (MRI) to promote ethical value-based payment contracting, health plans operate without substantial oversight. MRI's attempts to address these issues through state agencies and legislative offices have highlighted the lack of effective legal channels for reporting and investigating health plan misconduct. The document emphasizes the need for substantial investments in oversight mechanisms, including outcome measurement technology, ethics point portals, and independent audits, to ensure ethical value-based payment contracting.
https://www.mentorresearch.org/exposing-loopholes-how-health-plans-can-exploit-regulatory-gaps-1
Analysis of Moda Health's Code of Conduct and Allegations of Violations - Appendix 1
The article examines discrepancies between Moda Health's publicly stated Code of Conduct and its actual contracting practices with healthcare providers. Allegations include mid-contract changes to performance metrics, retroactive penalties, and a lack of transparency in financial calculations, which contradict Moda’s commitments to fairness and integrity. These actions have led to provider mistrust and raise concerns about whether Moda Health is adhering to its own ethical standards. The article underscores the need for independent oversight and regulatory intervention to ensure accountability and fairness in Moda’s business practices.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violations
1. Strengthen Independent Oversight and Enforcement
HB 3725 Legislative Void and Regulatory Gaps
HB 3725 creates an independent Mental Health Parity Ombudsman, but its investigative authority lacks enforcement powers.
No penalties are specified for non-compliance with parity laws, contract transparency, or provider protections.
No audit requirements are specified for health plan compliance.
Proposed Legislative Addition: Independent Oversight Boards with Enforcement Powers
SECTION XX: HEALTH PLANS SHALL ESTABLISH INTERNAL INDEPENDENT HEALTH PLAN BOARDS
(1) An Independent Health Plan Oversight Board must be established within each Health Plan to:
(a) Conduct annual audits of health plan contracts, ensuring compliance with ORS 743A.168 and HB 3725.
(b) Investigate complaints submitted by healthcare providers regarding ambiguous, unethical, fraudulent, or anticompetitive practices by the health plan.
(c) Issue decisions and recommendations to Health Plan management concerning unethical, abusive, illegal actions or non-compliance with state laws or regulations including contract transparency, parity law adherence, and network adequacy standards.
(d) Publish an annual report detailing audit findings, enforcement actions, and recommendations for legislative improvements to the legislature.(2) The Independent Health Plan Oversight Boards are empowered to request records and testimony from health plans during investigations.
(3) An Independent Health Plan Oversight Board does not report to (is not under) health plan management except to publish audit results to health plan management. They report to the Board of Directors and the Oregon Legislature.
The Dangers of Relying an Ombudsman for Illegal Contracting, Fraud and Antitrust Complaints: Undermining Accountability and the Legal Process
The paper discusses the risks of relying on ombudsmen to address cases of fraud and antitrust violations. It argues that ombudsmen may lack the authority and independence necessary to enforce accountability, potentially delaying or undermining legal actions. The discussion highlights how this approach can create conflicts of interest and insufferable delays, allowing fraudulent practices to persist while giving a false impression of oversight. The paper advocates for stronger, independent regulatory mechanisms to handle such violations effectively.
https://www.mentorresearch.org/the-danger-of-using-an-ombudsman-in-cases-of-fraud-and-violations-for-antitrust
The Independence of Healthplan Auditors Must Comport with Standards Set the U.S. Office of Inspector General (OIG)
This discussion paper outlines the value of using Office of Inspector General (OIG) standards in health plan contracting and compliance. It explains how OIG standards provide a framework for preventing fraud, waste, and abuse through clear guidelines on ethics, accountability, and internal controls. The paper discusses how adopting these standards can promote transparency, enhance oversight, and build trust between providers and health plans. Recommendations for integrating OIG standards into organizational policies and practices are also included.
https://www.mentorresearch.org/why-use-oig-standards
What Can Happen if Unfair, Bad Faith, Ambiguous, Ill-Defined, Unethical, or Voidable Provisions in Fee-For-Service and Value-Based Contracts Go Unchallenged?
This discussion paper examines the risks associated with voidable provisions in health plan contracts. It explains how these clauses allow one party to unilaterally alter or terminate key terms, creating instability and potential legal risks for providers. The paper outlines strategies for identifying and addressing voidable provisions, advocating for clearer contract language and mutual consent when changes are made. Recommendations for promoting more transparent and reliable contracting practices are also provided.
https://www.mentorresearch.org/contracts-with-voidable-provisions
2. Closing Loopholes in Health Plan Contracting & Transparency
HB 3725 Legislative Void and Regulatory Gaps
Health plans can hide risk-sharing methodologies and retroactively alter performance metrics.
No standard disclosure requirements exist for financial risk, reimbursement rates, or incentive structures.
Proposed Legislative Addition: Standardize Value-Based Payment Contract Transparency
SECTION XX: CONTRACT DISCLOSURE REQUIREMENTS FOR VALUE-BASED PAYMENT MODELS
(1) Any health plan offering value-based payment (VBP) contracts must:
(a) Provide detailed written disclosure of all risk-sharing arrangements, including: Expected financial exposure for participating providers. Historical reimbursement rates for the prior five years. Performance metric methodologies, including formulas used to assess compliance.
(b) Prohibit changes to contract terms without contracted providers’ consent and adequate notice.
(c) Mandate that contracts use plain language, avoiding ambiguous or undefined terms.
(d) Require an independent third-party review of all contracts before execution.(2) Health plans must provide an annual report to the Department of Consumer and Business Services (DCBS) containing:
(a) A comprehensive summary of provider payments and penalties imposed under VBP contracts.
(b) Anonymized provider survey results measuring satisfaction with contract fairness and transparency.
(c) A list of any contract complaints, disputes or legal actions initiated by providers in the past year.
Contracts and Policies Shall be Written in Plain, Understandable Language
This discussion paper advocates for health plan contracts and policies to be written in plain language. It explains how complex legal jargon can create misunderstandings, hinder compliance, and lead to disputes between providers and health plans. The paper emphasizes the benefits of using clear, straightforward language, including improved communication, enhanced trust, and easier contract implementation. Recommendations for adopting plain language standards and examples of effective contract language are also provided.
https://www.mentorresearch.org/contracts-and-policies-shall-be-written-plain-language
Contracts Shall Include Complete Descriptions of Reimbursement Algorithms Such that Another Auditor Following the Instructions Would Achieve the Same Results
This discussion article examines the importance of including complete descriptions of reimbursement algorithms in health plan contracts. It outlines how vague or incomplete algorithm descriptions can lead to confusion, billing disputes, and financial uncertainty for providers. The article recommends incorporating transparent and detailed language to clarify how reimbursement is calculated, ensuring that providers fully understand payment terms and reducing the risk of misinterpretation. Approaches for negotiating clearer contract language are also discussed.
https://www.mentorresearch.org/complete-descriptions-of-reimbursement-algorithms-in-contracts
3. Strengthening Whistleblower Protections
HB 3725 Legislative Void and Regulatory Gaps
HB 3725 provides some whistleblower protections, but the present bill lacks penalties for retaliation and does not cover all forms of retaliation.
Proposed Legislative Addition: Expanded Whistleblower Protections & Anti-Retaliation Measures
SECTION XX: PROTECTIONS FOR HEALTHCARE PROVIDERS REPORTING CONTRACT VIOLATIONS
(1) No health plan may retaliate against a healthcare provider for:
(a) Filing a complaint regarding unethical contracting practices or fraud.
(b) Participating in investigations conducted by regulatory agencies.
(c) Refusing to sign a contract containing misleading or unethical provisions.(2) Retaliation includes, but is not limited to:
(a) Termination or refusal to renew a contract based on a provider’s participation in regulatory reporting.
(b) Deliberate reduction in reimbursement rates following a provider's filing of a complaint.
(c) Blacklisting providers from future network inclusion.(3) Providers who experience retaliation are entitled to:
(a) Triple damages for financial losses resulting from retaliation.
(b) Reinstatement of contract terms if unjustly altered.
(c) A private right of action against the health plan, allowing them to sue for damages in state court.(4) The DCBS shall establish an anonymous and self-identified reporting system for providers to file complaints without fear of retaliation.
Why do Providers Avoid Conflicts with Healthplans?
This discussion paper explores why providers often avoid conflicts with health plans despite facing unfavorable or even unlawful contract terms. It outlines factors such as fear of retaliation, potential exclusion from networks, and the administrative burden of disputes. The paper discusses how these dynamics can undermine providers’ ability to advocate for better conditions and impact care quality. Recommendations for addressing these challenges include stronger legal protections and transparent dispute resolution processes.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplans
Whistleblower Protections in Oregon: Rights, Incentives, and the Role of Public and Private Funding
This discussion paper examines the legal protections and financial incentives available to whistleblowers in Oregon, highlighting disparities based on whether misconduct involves public or private funding. Whistleblowers reporting fraud related to public programs, such as Medicaid and Medicare, benefit from strong legal safeguards and potential financial rewards under statutes like the False Claims Act. However, those exposing unethical practices within private health plans face weaker protections and no financial incentives, leaving them vulnerable to retaliation. The article underscores the importance of strengthening whistleblower protections, establishing independent reporting mechanisms, and ensuring legal accountability for both public and private sector violations. Consulting legal experts and regulatory agencies is essential for navigating the complexities of whistleblower laws and safeguarding those who report misconduct.
https://www.mentorresearch.org/whistleblower-protections-in-oregon-rights-incentives-and-the-role-of-public-and-private-funding
4. Strengthening Antitrust & Market Manipulation Protections
HB 3725 Legislative Void and Regulatory Gaps
No enforcement mechanism exists to prevent health plans from misrepresenting network adequacy or blocking new providers from entering the market.
Health plans can manipulate risk adjustment methodologies to inflate profits.
Proposed Legislative Addition: Health Plan Antitrust & Market Fairness Enforcement
SECTION XX: PROTECTIONS AGAINST HEALTH PLAN MARKET MANIPULATION
(1) Health plans must publicly disclose:
(a) Annual network adequacy reports, including: (1) The number of participating providers per region. (2) The average wait time for behavioral and mental health appointments. (3)A list of group and individual providers who left the network, along with stated reasons.
(b) Risk and risk adjustment methodologies, including: The formulas used to calculate provider payments. Justifications for any payment reductions tied to risk adjustments.(2) Prohibited Practices:
(a) Health plans may not use exclusive contracts that limit provider access to competing networks.
(b) Health plans may not misrepresent provider participation to public purchasers such as Oregon Education Benefits Board (OEBB) or Public Education Benefits Board (PEBB).
(c) Health plans may not alter reimbursement formulas mid-contract without independent review.(3) Enforcement & Penalties:
(a) Any violation of this section is subject to: (1) A fine of up to $5 million per occurrence. (2) Suspension of state contracts for repeat violations. (3) Public disclosure of violations, including health plans placed under investigation.
Is Moda Health Violating Antitrust Law?
This discussion paper examines whether Moda Health’s contracting practices may violate antitrust laws. It analyzes how certain behaviors, such as limiting provider networks, restricting competition, and using exclusionary tactics, could create unfair market advantages. The paper outlines the potential antitrust implications of Moda Health’s actions and discusses how these practices may impact market pricing, provider autonomy, and patient access to care. Recommendations for further investigation and strategies to address potential antitrust violations are also included.
https://www.mentorresearch.org/is-moda-health-violating-antitrust-law
5. Closing Ethics Point Portal Loopholes
HB 3725 Legislative Void and Regulatory Gaps
HB 3725 does not define how an Ethics Point Portal should operate, allowing health plans to create internal, non-independent reporting systems.
No requirement for independent oversight of ethics reporting mechanisms.
Proposed Legislative Addition: Independent Ethics Reporting & Accountability Measures
SECTION XX: ESTABLISHMENT OF INDEPENDENT ETHICS POINT PORTALS
(1) The State of Oregon as well as any health plan receiving state funds and health plans offering commercial contracts must:
(a) Establish an independent Ethics Point Portal, managed by a third-party compliance firm.
(b) Allow anonymous or self-identified reporting of unethical contracting practices.
(c) Provide annual transparency reports summarizing: The number of complaints received. The nature of reported violations. Corrective actions taken.(2) Enforcement:
(a) Health plans that fail to establish an independent portal shall be fined up to $500,000 per year.
(b) Failure to act on ethics complaints within 90 days will result in automatic state investigation by DCBS.
Ethics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services
This discussion paper defines ethics point portals and outlines their benefits in health plan contracting. It explains how these portals provide a secure and confidential way for stakeholders to report unethical practices, compliance concerns, or contract violations. The paper highlights how ethics point portals promote transparency, accountability, and ethical conduct within organizations. Recommendations for implementing effective portals, including ensuring independence and accessibility, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefits
What Can Certified Internal Auditors Do That Will Prevent Healthplans From “Gaming” Providers, Purchasers, and The Public?
This discussion paper examines how value-based contracts can be manipulated through gaming tactics. It describes strategies such as selectively choosing patients, inflating risk scores, and misrepresenting outcomes to maximize financial incentives while undermining the contract’s intent. The paper discusses the impact of these practices on care quality, provider trust, and the effectiveness of value-based models. Recommendations for preventing gaming, including implementing clearer performance metrics and stronger oversight, are also provided.
https://www.mentorresearch.org/gaming-a-valuebased-contract
Why is Using an Independent Certified Internal Auditor within a Health Plan a Good Idea?
This discussion paper highlights the benefits of hiring an independent certified internal auditor (CIA) in health plan contracting. It explains how CIAs provide objective oversight, identify compliance issues, and ensure that contractual obligations are met fairly. The paper discusses how using independent auditors can promote transparency, reduce fraud risk, and build trust between contracting parties. Recommendations for selecting and integrating independent auditors into organizational governance are also included.
https://www.mentorresearch.org/why-hiring-an-independent-certified-internal-auditor-is-a-good-idea
Conclusion
These 5 additional legislative provisions would strengthen HB 3725 by:
Establishing independent contract audits & enforcement.
Mandating full transparency in value-based payment contracts.
Expanding whistleblower protections & anti-retaliation measures.
Strengthening health plan antitrust protections.
Ensuring that Ethics Point Portals are truly independent.
References
Preventing Crucial Legislative Voids and Regulatory Gaps in Oregon House Bill 3725
This article critiques Oregon House Bill 3725 (HB 3725), highlighting its shortcomings in addressing health plan accountability. While the bill introduces oversight mechanisms and reporting requirements, it lacks provisions to prevent health plan fraud, coercion, unethical behavior, and market manipulation. Notably, it does not grant enforcement powers to the proposed Mental Health Parity Ombudsman, nor does it impose penalties for non-compliance or mandate audits for health plan adherence. The article references a 2024 complaint filed by the Independent Mental Health Professional Alliance (IMHPA) against Moda Health, alleging bad faith and illegal contracting practices, which revealed a lack of accountability for such complaints under current Oregon law. To strengthen HB 3725, the article proposes five key provisions:
Strengthening Independent Oversight and Enforcement: Establish an Independent Health Plan Oversight Board within each health plan, equipped with enforcement powers to conduct annual audits, investigate provider complaints, and ensure compliance with state laws and regulations.
Enhancing Contract Transparency and Fairness: Mandate clear, plain-language contracts with standardized definitions, prohibit coercive contracting practices, and require disclosure of any changes to contract terms in a timely manner.
Implementing Whistleblower Protections: Provide robust protections for providers and employees who report unethical or illegal practices by health plans, including safeguarding against retaliation and ensuring confidentiality.
Establishing Penalties for Non-Compliance: Introduce meaningful penalties for health plans that violate parity laws, engage in fraudulent practices, or fail to comply with contract transparency requirements.
Requiring Independent Audits and Public Reporting: Mandate regular independent audits of health plans, with findings reported publicly to ensure transparency and accountability.
By incorporating these provisions, HB 3725 could become a robust law ensuring fairness, transparency, and protections for all mental health practices in Oregon.
https://www.mentorresearch.org/closing-critical-legislative-voids-and-regulatory-gaps-in-oregon-house-bill-3725Exposing Loopholes: How Health Plans Can Exploit Regulatory Gaps
This discussion document examines how health plans cab exploit regulatory gaps in Oregon to engage in unethical practices with minimal risk of consequences. Despite efforts by organizations like Mentor Research Institute (MRI) to promote ethical value-based payment contracting, health plans operate without substantial oversight. MRI's attempts to address these issues through state agencies and legislative offices have highlighted the lack of effective legal channels for reporting and investigating health plan misconduct. The document emphasizes the need for substantial investments in oversight mechanisms, including outcome measurement technology, ethics point portals, and independent audits, to ensure ethical value-based payment contracting.
https://www.mentorresearch.org/exposing-loopholes-how-health-plans-can-exploit-regulatory-gaps-1Moda Health's Termination of Contract Negotiations After Moda Negotiators Agreed to Ensure they Had a Certified Internal Auditor and an Ethics Point Portal
The article discusses the abrupt termination of contract negotiations by Moda Health with the Mentor Research Institute (MRI). Despite initial agreements to evaluate proposals for establishing an ethics point portal overseen by an independent auditor, Moda Health ceased discussions without clear justification. Since the State of Oregon will not investigate provider evidence and complaints regarding fraud or violations state and federal antitrust laws, this action raises concerns about Moda's commitment to ethical oversight, transparency, and good faith negotiations. The article suggests that such behavior may indicate a reluctance to implement independent auditing mechanisms, potentially to avoid external scrutiny of their contracting practices. This termination not only undermines trust between the parties involved but also highlights broader issues within healthcare contracting, where power imbalances and lack of accountability can adversely affect provider practices and patient care.
https://www.mentorresearch.org/moda-health-termination-of-contract-negotiations-with-mentor-research-instituteAllegations of Bad Faith, Fraud and Antitrust Violations by Moda Health Submitted to the Oregon Health Authority - Whistleblower Complaint
This paper discusses whistleblower allegations against Moda Health, including claims of bad faith contracting, fraud, and antitrust violations. It details how Moda allegedly uses deceptive contract terms and restrictive policies to limit competition and undermine independent practices. The article also compares these practices with legal standards to highlight potential breaches of antitrust and healthcare regulations, supporting the need for legal intervention.
https://www.mentorresearch.org/whistleblower-complaint-allegations-of-bad-faith-fraud-and-antitrust-violations-by-moda-healthAnalysis of Moda Health's Code of Conduct and Allegations of Violations - Appendix 1
The article examines discrepancies between Moda Health's publicly stated Code of Conduct and its actual contracting practices with healthcare providers. Allegations include mid-contract changes to performance metrics, retroactive penalties, and a lack of transparency in financial calculations, which contradict Moda’s commitments to fairness and integrity. These actions have led to provider mistrust and raise concerns about whether Moda Health is adhering to its own ethical standards. The article underscores the need for independent oversight and regulatory intervention to ensure accountability and fairness in Moda’s business practices.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violationsProtecting Minorities and Underserved Populations: Value-Based Contract Challenges
The article discusses the need for safeguards in value-based contracts to protect minority and underserved populations from systemic inequities. It emphasizes the importance of standardized definitions, clear language, whistleblower protections, and independent oversight to prevent exploitation and ensure transparency. Without these measures, providers serving vulnerable communities may face financial instability, limiting patient access to care. The article advocates for equitable contracting practices that promote health equity and sustainable care models.
https://www.mentorresearch.org/value-based-contracts-protecting-minorities-and-underserved-populationEmpowering Providers to Report Suspicious, Unethical, and Illegal Behaviors
The article highlights the importance of supporting healthcare providers in reporting unethical, illegal, or suspicious practices within value-based contracts and broader healthcare systems. It discusses barriers to reporting, such as fear of retaliation, lack of clear reporting channels, and contractual restrictions imposed by health plans. The article advocates for stronger whistleblower protections, independent oversight, and transparent reporting mechanisms to ensure providers can expose fraud, coercion, and unethical practices without jeopardizing their careers. Strengthening these safeguards is essential for maintaining ethical healthcare delivery and protecting both providers and patients.
https://www.mentorresearch.org/empowering-providers-to-report-suspicious-unethical-and-illegal-behaviorsSuccessful and Failed Case Studies of Measurement-Based Care and Value-Based Payment Contracts: Recommended Requirements
This discussion article compares successful and failed value-based contracts in healthcare. It analyzes the key factors that contribute to each outcome, such as clear performance metrics, aligned incentives, and effective care coordination. The article highlights common pitfalls in failed contracts, including poor communication, misaligned goals, and inadequate data sharing. Lessons learned from these case studies are presented to guide the development of value-based contracts that can achieve better clinical and financial results.
https://www.mentorresearch.org/successful-and-failed-valuebased-contractsCreating a Value-Based Payment Model: A Stepwise Approach to Success
This discussion paper outlines a structured approach to developing and implementing value-based payment (VBP) models in mental and behavioral health services, transitioning from traditional fee-for-service to performance-based contracting. The paper emphasizes the necessity of a deliberate framework to align provider incentives with patient outcomes, enhance transparency, ensure legal compliance, foster collaboration, and mitigate financial and operational risks.
Key Steps:
Establish Clear Objectives and Shared Values: Define common goals such as improving patient outcomes, enhancing care coordination, reducing costs, and maintaining access to services.
Develop Transparent Contracts: Craft agreements in plain language, clearly outlining service scope, performance benchmarks, risk-sharing mechanisms, and quality assurance protocols to prevent misunderstandings and disputes.
Define Measurement and Performance Metrics: Implement measurement-based care with key performance indicators, including clinical outcomes, patient satisfaction, and service utilization rates, to objectively assess provider performance.
Implement Data Infrastructure and Analytics: Invest in technology systems capable of collecting, analyzing, and reporting data to support informed decision-making and continuous quality improvement.
Provide Training and Support: Offer education and resources to providers and staff to ensure understanding and effective participation in VBP models, fostering a culture of continuous improvement.
Establish Continuous Monitoring and Feedback Mechanisms: Regularly review performance data, provide feedback, and adjust strategies as needed to maintain alignment with objectives and respond to emerging challenges.
The paper concludes that a methodical, collaborative approach is essential for the successful adoption of VBP models, ultimately leading to improved patient care and more efficient healthcare delivery systems.
https://www.mentorresearch.org/creating-a-contracts-agreements-and-policy-for-value-based-mental-and-behavioral-health-servicesWhistleblower Protections in Oregon: Rights, Incentives, and the Role of Public and Private Funding
This discussion paper examines the varying degrees of legal safeguards and financial incentives available to whistleblowers in Oregon, contingent upon the nature of the funding involved—public or private. It highlights that individuals reporting misconduct related to public programs, such as Medicaid, Medicare, or the Oregon Health Plan, benefit from robust protections and potential financial rewards under statutes like the False Claims Act. Conversely, those disclosing issues within commercial health plans encounter more limited protections and lack financial incentives. The paper underscores the importance of consulting legal resources, including the Oregon Bureau of Labor and Industries (BOLI) or specialized attorneys, to navigate the complexities of whistleblower protections effectively, tailored to the specific funding context of the reported misconduct.
How and Why Should the Independence of Certified Internal Auditors be Ensured?
This discussion paper addresses the importance of maintaining the independence of internal auditors in health plan contracting. It explains how independent auditors can objectively evaluate compliance, detect unethical practices, and provide unbiased recommendations without external influence. The paper highlights common threats to auditor independence, such as conflicts of interest and management pressure, and offers strategies for preserving impartiality, including clear reporting structures and adherence to professional standards.
https://www.mentorresearch.org/maintaining-independence-of-internal-auditorsBreaking the Cycle of Unfunded Health Plan Mandates
The article discusses the challenges posed by health plans that impose administrative tasks on providers without offering corresponding compensation or support. This practice leads to operational inefficiencies, erodes trust between providers and payers, and hampers the effective implementation of value-based care models. The author advocates for health plans to invest in necessary infrastructure and collaborate with providers to ensure sustainable healthcare reform.
https://www.mentorresearch.org/breaking-the-cycle-of-unfunded-mandatesModa Health: Nine Actions and Their Consequences
The article examines nine specific actions taken by Moda Health in its contracting practices, highlighting the negative consequences for healthcare providers and the broader healthcare system. These actions include imposing non-negotiable contracts, utilizing ambiguous terms, retroactively altering performance metrics, and enforcing unfunded mandates. Such practices have led to increased administrative burdens, financial instability for providers, erosion of trust, and potential declines in patient care quality. The article advocates for transparent contracting, equitable risk-sharing, and independent oversight to mitigate these adverse effects and promote ethical value-based care.
https://www.mentorresearch.org/moda-health-9-actions-and-the-consequencesContract Negotiation Tactics Used by Health Plans
The article examines strategies employed by health plans during contract negotiations that can undermine mental health services by limiting providers' ability to negotiate effectively. These tactics include presenting non-negotiable, "take-it-or-leave-it" contracts; using strategic ambiguity to leave critical terms undefined; implementing contract ratcheting by progressively increasing administrative demands; maintaining network secrecy by withholding information about participating providers; and imposing unfunded mandates that require providers to absorb additional costs without reimbursement. By identifying these practices, providers can better anticipate potential risks and advocate for fairer contract terms during negotiations.
https://www.mentorresearch.org/contract-negotiation-tactics-used-by-health-plansThe Fallacy of Better, Cheaper, Faster: How Health Plans Shift Risk to Providers
The article examines how health plans promote value-based contracts under the premise of delivering better, cheaper, and faster healthcare services. In reality, these contracts often transfer significant financial and operational risks onto providers. Tactics include imposing rigid service caps, reducing payment rates, and increasing administrative burdens, all of which can lead to inadequate patient care and provider burnout. The article calls for greater transparency, fair contract terms, and regulatory oversight to ensure that health plans share financial risks equitably and invest in genuine improvements in care quality.
https://www.mentorresearch.org/the-fallacy-of-better-cheaper-faster“Solutionism” in Healthcare: Moda Health’s Contracting Approach and Consequences
The article critiques Moda Health's reliance on "solutionism" the belief that complex healthcare issues can be resolved through technical solutions without addressing underlying systemic problems. Moda's implementation of measurement-based care, incentive-based payments, and administrative streamlining is seen as superficial, failing to consider deeper issues such as unethical contracting practices, lack of transparency, and provider burnout. This approach may lead to unintended consequences, including reduced care quality and erosion of trust between providers and payers.
https://www.mentorresearch.org/solutionism-in-healthcare-moda-healths-contracting-approach-and-consequencesThe Dangers of Using an Ombudsman for Fraud and Antitrust Violations: Undermining Accountability and the Legal Process.
The paper discusses the risks of relying on ombudsmen to address cases of fraud and antitrust violations. It argues that ombudsmen may lack the authority and independence necessary to enforce accountability, potentially delaying or undermining legal actions. The discussion highlights how this approach can create conflicts of interest, allowing fraudulent practices to persist while giving a false impression of oversight. The paper advocates for stronger, independent regulatory mechanisms to handle such violations effectively.
https://www.mentorresearch.org/the-danger-of-using-an-ombudsman-in-cases-of-fraud-and-violations-for-antitrustContract “Gaming”: Reasons Why Value-Based Contracts Can Fail.
This discussion paper analyzes various forms of contract gaming that can undermine the success of value-based contracts. It describes tactics such as manipulating patient risk scores, selective reporting of outcomes, and redefining performance metrics to skew results. The paper explains how these practices can distort the intended goals of value-based care, leading to mistrust and reduced effectiveness. Strategies to identify and prevent contract gaming, including stronger oversight and clearer definitions, are also discussed.
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-failWhen Denial Becomes Deadly
This article examines the public outcry over health insurance practices following the killing of UnitedHealthcare CEO Brian Thompson. It highlights growing frustrations with insurers prioritizing profits over patient care, with high claim denial rates and prior authorization delays leading to worsened health outcomes. The piece also explores the role of algorithms in increasing denials and the financial burdens placed on patients. Social media reactions reflect deep-seated anger toward the healthcare system, emphasizing the urgent need for reforms to ensure fair and transparent insurance practices.
Ethics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
This paper defines ethics point portals and outlines their benefits in health plan contracting. It explains how these portals provide a secure and confidential way for stakeholders to report unethical practices, compliance concerns, or contract violations. The paper highlights how ethics point portals promote transparency, accountability, and ethical conduct within organizations. Recommendations for implementing effective portals, including ensuring independence and accessibility, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefitsEthics-Point Portals Overseen by Independent Certified Internal Auditors (CIA): A Resource to Serve Stakeholders and the Public.
This discussion paper emphasizes the importance of having ethics point portals overseen by an independent certified internal auditor (CIA). It explains how independent oversight ensures that reports of unethical practices or contract violations are handled objectively and free from internal influence. The paper highlights the benefits of this structure, such as increased trust, better compliance, and reduced risk of retaliation against reporters. Recommendations for maintaining auditor independence and promoting transparent investigations are also included.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditorControls in Fee-For-Service, Alternative and Value-Based Payment Contracting.
This discussion paper defines the concept of a "control" in the context of health plan contracting and compliance. It explains how controls are mechanisms put in place to ensure that operations align with established policies, prevent unethical behavior, and detect potential issues. The paper outlines different types of controls, such as preventative, detective, and corrective controls, and discusses their role in promoting accountability and reducing risk. Strategies for implementing effective controls within contracting frameworks are also provided.
https://www.mentorresearch.org/what-is-a-controlSigns of Bad Faith in Value-Based Payment Contracts for Mental and Behavioral Health Services Offered by Healthplans.
This discussion paper outlines signs of a bad faith value-based payment contract. It describes indicators such as vague performance metrics, unilateral changes to terms, and excessive administrative requirements that disadvantage providers. The paper also highlights how these contracts can undermine trust and compromise care quality. Strategies for identifying and avoiding bad faith contracts, as well as recommendations for promoting more transparent and equitable agreements, are also discussed.
https://www.mentorresearch.org/signs-of-a-bad-faith-valuebased-payment-contractHigh Case-Mix Severity Must be Considered in Value-Based Contracting.
This discussion paper addresses the importance of considering high case mix severity in value-based contracting. It explains how failing to account for complex patient populations can lead to unfair performance evaluations and inadequate reimbursement for providers. The paper highlights the need for risk adjustment methods that accurately reflect patient severity to ensure that value-based contracts are equitable and do not penalize providers who treat high-risk patients. Strategies for implementing effective risk adjustment measures are also discussed.
https://www.mentorresearch.org/high-case-mix-severity-must-be-considered-n-valuebased-contractingCreating a Value-Based Payment Model: A Stepwise Approach to Success
This discussion paper outlines a structured approach to developing and implementing value-based payment (VBP) models in mental and behavioral health services, transitioning from traditional fee-for-service to performance-based contracting. The paper emphasizes the necessity of a deliberate framework to align provider incentives with patient outcomes, enhance transparency, ensure legal compliance, foster collaboration, and mitigate financial and operational risks.
Key Steps:
Establish Clear Objectives and Shared Values: Define common goals such as improving patient outcomes, enhancing care coordination, reducing costs, and maintaining access to services.
Develop Transparent Contracts: Craft agreements in plain language, clearly outlining service scope, performance benchmarks, risk-sharing mechanisms, and quality assurance protocols to prevent misunderstandings and disputes.
Define Measurement and Performance Metrics: Implement measurement-based care with key performance indicators, including clinical outcomes, patient satisfaction, and service utilization rates, to objectively assess provider performance.
Implement Data Infrastructure and Analytics: Invest in technology systems capable of collecting, analyzing, and reporting data to support informed decision-making and continuous quality improvement.
Provide Training and Support: Offer education and resources to providers and staff to ensure understanding and effective participation in VBP models, fostering a culture of continuous improvement.
Establish Continuous Monitoring and Feedback Mechanisms: Regularly review performance data, provide feedback, and adjust strategies as needed to maintain alignment with objectives and respond to emerging challenges.
The paper concludes that a methodical, collaborative approach is essential for the successful adoption of VBP models, ultimately leading to improved patient care and more efficient healthcare delivery systems.
https://www.mentorresearch.org/creating-a-contracts-agreements-and-policy-for-value-based-mental-and-behavioral-health-servicesValue-Based Payment Contracting for Psychotherapy Services: Requirements and Challenges
This draft discussion paper, dated April 2024, provides a comprehensive overview of the complexities involved in implementing value-based payment (VBP) models within psychotherapy services. It emphasizes the shift from traditional fee-for-service models to VBP, which focuses on quality and patient outcomes rather than service volume. The paper outlines the high risks and complexities associated with VBP contracting, highlighting the need for provider practices to possess significant experience, resources, and strategic approaches to navigate these intricacies effectively.
Key Points:
High-Level Guidance and General Challenges: The transition to VBP in psychotherapy demands expert knowledge, appropriate business structures, financial resources, and experience in contract administration, internal auditing, and risk management. Providers must meet health plan targets while negotiating contracts that allow for reasonable profit and manage the probable risk of financial loss.
Requirements for Successful Implementation: Effective VBP implementation necessitates significant investment by health plans, technology adoption, knowledge of psychotherapy, data analytics, and ethical practices. Provider groups need extensive experience in measurement-based care (MBC) and the capability to gather, aggregate, and analyze data to establish baselines and benchmarks for successful contract negotiation and management.
Opportunities and Challenges with VBP: VBP presents opportunities for improving treatment adherence, patient-centric care models, quality improvement, and incentivization of effective providers. However, challenges include the rarity of independent psychotherapists in VBP arrangements, lack of standardized outcome measures, separation from physical health care systems, undervaluation by payers, complexity of mental health conditions, ethical considerations, risk of adverse selection, and resource limitations.
Negotiating VBP Contracts: The paper outlines strategies for negotiating VBP contracts, emphasizing the importance of assessing provider practice capabilities, understanding the value proposition, identifying measurable outcomes, evaluating legal terms and financial risks, and fostering collaboration and partnership with payers.
Potential Pitfalls and Challenges: Participating in a VBP contract can lead to loss of control over patient care, fragmentation of services, challenges with performance metrics, financial risks, and potential for increased administrative burdens.
The document serves as a living resource, subject to revision as new information and perspectives emerge, aiming to guide providers through the evolving landscape of value-based payment in psychotherapy services.
https://www.mentorresearch.org/value-based-payments-psychotherapy
DISCLAIMER and PURPOSE: This discussion document is intended for training, educational, legislative, and or research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.
For more information see: https://www.mentorresearch.org/disclaimer-and-purpose